Anesthesia for patients with PTRF mutations: a case report.

BACKGROUND: Polymeraze I and transcript release factor (PTRF) mutations are a newly recognized disease, which cause congenital generalized lipodystrophy associated with myopathy. CASE PRESENTATION: A 29-year-old man (height 126 cm; weight 22 kg) with a PTRF mutation was scheduled for mandibular dentigerous cystectomy. His primary symptoms were lipodystrophy, myopathy, long QT syndrome, refractory nephrosis, and abnormal lipid metabolism. Defibrillator pads were applied soon after the patient entered the operating room. Anesthesia was induced using continuous administration of dexmedetomidine (4 µg/kg/h) for 15 min; midazolam (7 mg) was added while monitoring the bispectral index and his vital signs. Remifentanil and rocuronium were administered before endotracheal intubation. The surgeon used local anesthesia, and dexmedetomidine and remifentanil were titrated throughout the surgery. The surgery was performed uneventfully, and the patient was extubated following the administration of sugammadex and flumazenil. CONCLUSION: Patients with PTRF mutations require careful anesthetic planning. We planned to administer lipid-free, non-inhalational agents for the induction and maintenance of anesthesia. The anesthetic method used for this minor surgery was safe and effective.

Erector spinae plane block for low back pain in failed back surgery syndrome: a case report.

BACKGROUND: Patients with failed back surgery syndrome (FBSS) experience chronic back pain following spinal surgery, and effective treatment is difficult because of multiple contributing factors. CASE PRESENTATION: Here we report a case involving a 72-year-old woman who experienced recurrent low back pain after undergoing two back surgeries. She was treated with erector spinae plane (ESP) block, which affected the dorsal rami of the spinal nerves from T12 to L5. Pain relief lasted for approximately 10 h after the initial block, and successful low back pain relief was achieved after a total of three trials. CONCLUSIONS: ESP block, which is an easy and safe procedure, can be used to treat FBSS-associated low back pain.

Therapeutic effects of flurbiprofen axetil on mesenteric traction syndrome: randomized clinical trial.

BACKGROUND: This study aimed to reveal the appropriate timing for the intravenous administration of flurbiprofen axetil for preventing mesenteric traction syndrome (MTS), caused by prostacyclin release. METHODS: In this prospective, randomized, clinical study, forty-five patients who were undergoing elective surgery for colorectal cancer via laparotomy were enrolled. Patients were randomly divided into 3 groups: a preoperative group (n = 16) receiving flurbiprofen axetil directly before surgery; a post-MTS group (n = 14) receiving following MTS onset; and a control group (n = 15) who were not administered flurbiprofen axetil. 6-keto-PGF1α, a stable metabolite of prostacyclin, levels were measured and mean blood pressures were recorded. RESULTS: In the preoperative group, 6-keto-PGF1α levels did not increase, blood pressure levels did not decrease, and no facial flushing was observed. In both the post-MTS and control groups, 6-keto-PGF1α levels increased markedly after mesenteric traction and blood pressure decreased significantly. The post-MTS group exhibited a faster decreasing trend in 6-keto-PGF1α levels and quick restore of the mean blood pressure, and the use of vasopressors and phenylephrine were lower than that in the control group. CONCLUSIONS: Even therapeutic administration of flurbiprofen axetil after the onset of MTS has also effects on MTS by suppressing prostacyclin production. TRIAL REGISTRATION: Clinical trial number: UMIN000009111 . (Registered 14 October 2012).

Complete Antethoracic Block for Analgesia After Modified Radical Mastectomy: A Case Report.

Complete antethoracic block for modified radical mastectomy is a composite block comprising the antethoracic medial, antethoracic inferior, and antethoracic lateral blocks. The puncture targets of all components are easy to identify, and the risk of complications such as pneumothorax is low. Our patient was a 72-year-old woman undergoing modified radical mastectomy for breast cancer. After induction of general anesthesia, but before surgical incision, she received a complete antethoracic block for anesthesia, which also provided good analgesia postoperatively. We believe that complete antethoracic block is suitable for postoperative analgesia in patients undergoing this surgery.

Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor.

BACKGROUND: Mesenteric traction syndrome (MTS) develops in the early phase of laparotomy, which is triggered by pulling of the mesentery. We attempted to analyze the circulatory dynamics of MTS by using the FloTrac sensor. METHODS: Prospective randomized control study, the MTS trial, was conducted with or without prophylactic administration of flurbiprofen axetil in order to control MTS development in 57 elective open colorectal surgeries. None of the Flurbipurofen group patients (n = 23) develop MTS and were allocated to the non-MTS group. Among the non-flurbiprofen group, 28 patients (82%) developed MTS and were categorized into the MTS group. For these patients, in addition to blood pressure, stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured by FloTrac sensor. RESULTS: The lowest blood pressure was noted within 30 minutes from the beginning of the intra-abdominal examination; in the non-MTS group, the mean blood pressure decreased by 16.7%, and in the MTS group, it decreased by 34.2% (P < .01). SVV of the 28 MTS patients was as follows: <9% in 10 patients (35.7%), >9% and <13% in 8 patients (28.6%), and >13% in 10 patients (35.7%). SVRI rose in the non-MTS group by 5.1%, whereas it fell in the MTS group by 15.1% (P < .01), indicating the close relationship between MTS and SVRI. CONCLUSIONS: The SVV results indicate that fluid loading is not that optimal treatment against hypotension of MTS and that it is also important to consider the use of a vasoconstrictor. FloTrac is therefore useful for making an appropriate decision on the treatment strategy for MTS.

[The preventive effect of flurbiprofen on preventing mesenteric traction syndrome].

BACKGROUND: Mesenteric traction syndrome (MTS) is associated with facial flushing, hypotension and tachycardia. The ways to treat MTS are fluid replacement, administration of vasopressors and nonsteroidal anti-inflammatory drugs (NSAIDs) such as flurbiprofen. In order to stabilize the hemodynamics during operation, preventing MTS is more reasonable. Thus, we investigated the preventive effect of flurbiprofen on MTS, the only injectable formulation which can be used in Japan. METHODS: In a prospective randomized study, 24 patients undergoing elective colorectal surgery were assigned to two groups. In one group (n = 11 group F), flurbiprofen (1 mg x kg(-1), 50 mg max) was administered before surgery. In the second group (n = 13; group C), flurbiprofen was not administered. After laparotomy, presence of facial flushing and blood pressure reduction were compared. MTS is defined as facial flushing with concomitant blood pressure reduction. RESULTS: MTS occurred in no patients in group F, but in 11 patients in group C (84.6%, P < 0.05). In cases of the patients in which MTS appeared, facial flushing was observed at 5.9 +/- 5.2 min after starting mesenteric manipulation, and the mean reduction in blood pressure was 40.3% at 9.9 +/- 4.4 min after starting mesenteric manipulation. CONCLUSIONS: Our results indicate that pretreatment with flurbiprofen might prevent MTS.

[Combined use of the Airway Scope and gum elastic bougie for tracheal intubation in a patient with an epiglottic cyst].

A 71-year-old man with sigmoid colon cancer was scheduled for the sigmoidectomy under general anesthesia. In preoperative examination, an epiglottic cyst was found accidentally. He had no subjective symptom. Rapid induction with remifentanil, propofol, rocuronium and ephedrine was performed, and the mask ventilation was easy. The Airway Scope (AWS) was inserted at first, but it was difficult to intubate because of the epiglottic cyst. Then a gum elastic bougie (GEB) was inserted under observation by AWS monitor. GEB was passed into the trachea, and the tube was passed over the GEB into the trachea. Combined use of AWS and GEB is useful for endotracheal intubation in a patient with a epiglottic cyst.

[Effect of individualized goal directed therapy on outcome after major sugery].

BACKGROUND: Goal directed therapy (GDT) is applied during the initial resuscitation of sepsis, known as early goal directed therapy (EGDT). Recent studies in major abdominal surgery suggested that anesthetic management with GDT may decrease morbidity and hospital stay. We have utilized GDT in major invasive surgery such as pancreatoduodenectomy in November 2009. METHODS: In the anesthetic management of pancreatoduodenectomy, 11 patients managed by GDT were compared concerning postoperative hospital stay with 11 patients managed by conventional methods retrospectively. In our GDT protocol, we have set targets in mean blood pressure, oxygen saturation, and stroke volume variation, which is more individualized for each one. With falls below the target, fluid infusion, blood transfusions, and circulatory agonists were administered. In the conventional protocol, anesthesiologist managed the use of anesthetic agents, fluid infusion, blood transfusion, and circulatory agonist, through the observation of the operative field, blood pressure, heart rate and urine output. RESULTS: Patients utilizing the GDT showed shorter postoperative hospital stay (group GDT; 21.8 days vs conventional group; 32.6 days. P<0.05). CONCLUSIONS: Anesthetic management with goal-directed therapy, may have contributed to shorter postoperative hospital stay.

[Fentanyl induced intraoperative anaphylactic reaction].

We report a case of intraoperative fentanyl anaphylactic reaction. The patient was a previously healthy 12-year-old boy with severe head injury by a traffic accident. We experienced a rapid hemodynamic change after fentanyl injection and that occurred again after another fentanyl injection. In the second hemodynamic change, red wheals appeared on the skin. We clinically diagnosed this as fentanyl anaphylactic reaction. Six weeks later we performed prick test and intradermal test, but the patient had negative results for fentanyl in both tests. Although it is rare that opioids cause anaphylactic reaction, we must differentiate them when we search causative agents. Even if skin tests are negative, there is a possibility of false negative reactions. Therefore it is safe to regard suspicious agents as causative agents in cases where the agents are clinically suspected.

[Introduction of enhanced recovery after surgery (ERAS) protocols: reducing 3.4 days of postoperative hospital stay].

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reducing complication rates, and shortening hospital stay following colorectal surgery in Europe. In cooperation with colorectal surgeons, ERAS protocols were initially introduced in our hospital to the patients undergoing open colorectal resection in July 2010. METHODS: Length of postoperative hospital stay was compared of 139 consecutive patients undergoing open colorectal resection before (n = 96) and immediately after implementing ERAS (n = 43). RESULTS: In the ERAS group, length of postoperative hospital stay was significantly reduced from 12.7 +/- 7.7 to 9.3 +/- 6.2 days (P < 0.0001). Oral intake, one of important ERAS elements, both before and after surgery had dramatically changed, implying tolerance of ERAS protocol in Japan. CONCLUSIONS: We, anesthesiologists as perioperative physicians, can improve key elements of perioperative care such as patients' counseling, perioperative analgesia and early mobilization by collaboration with surgeons and nurses, to facilitate postoperative recovery.

[Change of surgeons' opinion against anesthesiologists after introduction of enhanced recovery after surgery (ERAS) protocols: questionnaire survey among surgeons who participated ERAS care].

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols aim to improve patient care, reducing complication rates, and shortening hospital stay following colorectal surgery in Europe. In cooperation of colorectal surgeons and anesthesiologists, ERAS protocols were initially introduced in our hospital to the patients who underwent open colorectal resection in July 2010. METHODS: Using a questionnaire, we surveyed the change of surgeons' opinion against anesthesiologists after introduction of ERAS among 15 surgeons at Metropolitan Bokutoh hospital. RESULTS: Surgeons realized that introduction of ERAS made strong communication between surgeons and anesthesiologists. And they also thought it is not surgeons themselves nor anesthesiologists themselves but 'team care' which could produce positive outcome of ERAS. CONCLUSIONS: Introduction of ERAS as collaboration of surgeons and anesthesiologists resulted in facilitating communication of surgeons and anesthesiologists.

[Anesthesia induction for patients with cervical spinal disease].

BACKGROUND: In the cases in which the flexibility of the patient's neck is limited, it is often difficult to achieve intubation. Fiberoptic intubation has been chosen for patients with arthroses. However, as it requires techniques, it has been difficult for inexperienced anesthesiologists. METHODS: Awake induction using AirWay Scope was performed for 8 patients with cervical spinal diseases. Midazolam, propofol or dexmedetomidine is selected as a sedative drug. RESULTS: Intubation was performed easily and safely without any complications in all cases. No patients had memories of intubation. CONCLUSIONS: Awake intubation using AirWay Scope for patients with cervical spinal diseases is a safe and useful anesthesia method. As dexmedetomidine causes no respiratory depression and can expect cooperation from patients, it may give safe and efficient sedation in awake intubation cases.

[Postoperative analgesia for the laparoscopic cholecystectomy].

BACKGROUND: As laparoscopic cholecystectomy is assumed to be with less postoperative pain, it is managed only by general anesthesia during the surgery in our hospital. However, about 70 percent of cases needed the additional analgesic drugs after the operation. In addition, about 70 percent needed analgesic drugs within three hours after the operation, and it has been understood that early postoperative analgesia is insufficient. We focused on the ultrasound guided nerve block and used it to relieve postoperative pain after the laparoscopic cholecystectomy. METHODS: Forty three cases managed by the general anesthesia alone are compared with 9 cases managed with the nerve block of the trunk in for the laparoscopic cholecystectomy. RESULTS: Pain score early after the operation, the ratio of patient who used analgesic drug, and the frequency of its use are all decreased by performing the block. CONCLUSIONS: The use of ultrasound guided nervous block for the postoperative pain after laparoscopic cholecystectomy has been helpful, and excellent pain relief has been obtained.