Propofol suppresses both the sympathetic and parasympathetic nervous systems. There have been no clinical studies examining the infusion rate-related hemodynamic interaction between propofol and landiolol, an ultra-short-acting β 1- blocking agent. Twenty-four patients were divided into two groups. Patients in the P-1.25 group (n＝12) received intravenous (IV) propofol (1.25 mg / kg) over 1 min followed by continuous infusion of propofol at 5 mg / kg / h. Tracheal intubation was facilitated with IV rocuronium, and anesthesia was maintained with propofol at 5 mg / kg / h and 67% nitrogen in oxygen. Patients in the P-2.5 group (n＝12) received IV propofol (2.5 mg / kg) over 1 min followed by propofol at 10 mg / kg / h. All other protocols were identical to those in the P-1.25 group. Fifteen minutes after tracheal intubation, patients in both groups received IV landiolol at incremental infusion rates (40, 50, 60, 70, 80, 90, and 100 μ g / kg / min for 2 min at each dose). Changes in heart rate (HR) were greater in patients in the P-1.25 group than the P-2.5 group. The landiolol infusion at 40, 50, or 60 μg / kg / min caused HR changes of －6±4, －9±6, and －13±6 beats / min (bpm) in the P-1.25 group, while the HR in the P-2.5 group decreased by －1±3, －4±2, and －6±4 bpm (mean±SD, P＜0.05). When landiolol was infused at a rate of 90 μg / kg / min, HR decreased by more than 15 bpm in all patients in the P-1.25 group, but only 40% of patients in the P-2.5 group. We conclude that the HR response to IV landiolol is attenuated at higher propofol infusion rates.
A 66-year-old man with recurrence after right middle and lower lobectomy for lung cancer underwent completion pneumonectomy with peri- cardiotomy. He had a medical history of angina and had undergone percutaneous coronary intervention one year earlier. At the time of emergence from general anesthesia, he suffered ventricular fibrillation, which led to cardiac arrest following a coughing fit. After the return of spontaneous circulation following cardiopulmonary resuscitation, chest X-ray showed findings of cardiac herniation even though the pericardium had been closed with an artificial pericardium. Circulatory dynamics improved after the replacement of the heart and repair of the pericardium with re-thoracotomy. When circulatory disturbance occurs in a patient after complete pericardium closure with artificial pericardium after completion pneumonectomy with pericardiotomy, it is necessary to keep in mind the possibility of cardiac herniation and confirm the diagnosis promptly using imaging.
Intraoperative positive pressure ventilation may cause a pneumothorax in patients with pulmonary emphysema, resulting in intraoperative hypoxic events. Here we report a case of thoracic endovascular aortic repair (TEVAR) under veno- venous extracorporeal membrane oxygenation (vvECMO) support. A 76-year-old man was diagnosed with a distal aortic arch aneurysm. He also had a pulmonary emphysema complicated with refractory pneumothorax. After endotracheal bronchial embolization, TEVAR was performed under general anesthesia with endotracheal intubation. To prevent intraoperative hypoxic events, vvECMO was employed during the stent-graft implantation. This technique may be useful for safely performing TEVAR in patients with pulmonary emphysema.
Sinus of Valsalva aneurysm (SVA) is a rarecardiac defect that can be congenital or acquiredthrough infection, trauma, or degenerative diseases.A 79-year-old man was diagnosed with upper jawcancer and in preoperative transthoracic echocardiographyand computed tomography was foundto have an unruptured right SVA causing rightventricular outflow obstruction. Under generalanesthesia, surgical repair was performed afterinstituting cardiopulmonary bypass. We successfullyperformed the anesthetic management of theSVA surgical repair using transesophagealechocardiography.
We studied the effects of sevoflurane-N2O anesthesia on isoproterenol-induced heart rate (HR) changes. Twenty-six patients (ASA class I, 23-46 y) were assigned to two groups. The control group (n=13) received no sevoflurane and no N2O. Patients in the sevoflurane-N2O group (n=13) received 5% sevoflurane and 67% N2O in oxygen. After tracheal intubation with rocuronium, anes- thesia was maintained with an end-tidal sevoflurane concentration of 1.5%, together with 67% N2O in oxygen. Mechanical ventilation was performed to maintain EtCO2 at 35 mmHg. After 15 min, all patients in both groups received intravenous isopro- terenol at incremental infusion rates (2.5, 5, 7.5, 10, 12.5, 15, 17.5, and 20 ng/kg/min for 2 min at each infusion rate), until HR increased by more than 20 beats/min from baseline values. At the end of each infusion period, hemodynamic data were collected. Though there were no significant differences bet- ween the groups with respect to age and sex distri- bution, basal HR (before isoproterenol infusion) was significantly higher in the sevoflurane group than the control group. The HR responses to isoprote- renol at 2.5, 5.0, and 7.5 ng/kg/min were attenuated in the sevoflurane-N2O group as compared to the control group (0 ± 2 vs. 2 ± 3, 3 ± 4 vs. 9 ± 4, and 6 ± 5 vs. 14 ± 4 beats/min, respectively; mean ± SD, P<0.05 between groups). During isoproterenol infusion at 17.5 ng/kg/min, HR increased by more than 20 beats/min in all patients in the control group, but only in 7 (54%) patients in the sevoflurane group (P＜0.0001). These results suggest that a higher isoproterenol infusion rate may be required for the treatment of bradycardia or heart block in patients under sevoflurane-N2O anesthesia as compared to awake patients.
Heparin-induced thrombocytopenia(HIT) is a complication of anticoagulation therapy using heparin. We report a critical case of HIT during anticoagulation therapy with heparin and warfarin. A 67-year-old man was admitted to our hospital with deep vein thrombosis and pulmonary thromboembolism. Intravenous heparin and oral warfarin were initiated for anticoagulation. Eleven days after starting heparin therapy, the platelet count suddenly decreased to below 50,000/μ l, indicative of type 2 HIT. Twelve days after starting heparin, an above-knee amputation was required for warfarin-induced venous limb gangrene. During anticoagulation therapy with heparin, attention must be paid to the risk of critical HIT. Furthermore, the risk of warfarin causing venous limb gangrene in patients with HIT must be considered.
Although it is common to administer intrathecal morphine for relief of pain associated with cesarean section, persistent hypothermia is a little-known adverse effect of subarachnoid morphine administration. We report a case of persistent hypothermia after subarachnoid anesthesia during an elective cesarean delivery. The mother received subarachnoid anesthesia with 11 mg of hyperbaric bupivacaine along with an accidentally high dose of 1 mg of morphine. Shortly after delivery, her temperature was 36.1°C, decreasing at 2 hours after anesthesia induction to 34.0°C, in spite of active warming. At the time, the patient was heavily perspiring, and reported feeling hot and nauseous. Since the symptoms were suspected to be due to subarachnoid morphine, 0.2 mg naloxone was administered intravenously over a 10-minute period. Immediately after commencing naloxone administration, the patient felt cold and began shivering, her body temperature returned to 35.5°C after about 1 hour and did not decrease again, following which a stable course was observed. Delayed and persistent hypothermia attributed to accidental high-dose intrathecal morphine administration was reversed with naloxone administration.
Tachycardia and hypertension due to surgical and tourniquet pain often occur suddenly during general anesthesia for total knee arthroplasty. We evaluated the dose-related effects of landiolol on an abrupt tachycardic response in this clinical setting, since this agent is able to suppress the cardiovascular responses associated with sympathetic stimulation.After approval by the local ethical committee and informed consent, 114 patients, aged 51-89 yr, undergoing total knee arthroplasty under general anesthesia were enrolled in this study. Following general anesthesia induction with fentanyl 1-2 μg/kg, propofol 1.5-2 mg/kg and 5% sevoflurane, a laryngeal mask airway was inserted, and anesthesia was maintained with 1% sevoflurane, droperidol 5 mg and 50% N2O in oxygen. Thereafter, supplemental fentanyl 0.5-1 μg/kg was injected repeatedly to keep the end-tidal CO2 tension of 30-45 mmHg, and spontaneous respiratory rate of 10-25 breaths/min. When a tachycardic response(defined as heart rate of more than 90 beats/min for more than 3 minutes) was observed, landiolol or normal saline(as a time control group) was randomly infused continuously at a rate of 40 or 80 μg/kg/min, or of 0.24 mL/kg/h, respectively, until the end of surgery or tourniquet deflation. Hemodynamic and respiratory variables were recorded at 1-5 minute intervals. Data were analyzed by analysis of variance or Student's t-test with Bonferroni's correction for comparisons among groups or within each group, with p<0.05 being significant.Tachycardic responses developed in 50 of 114 patients(44%) studied. There were no significant differences in demographic data among patients who received landiolol 40 μg/kg/min(n＝24), landiolol 80 μg/kg/min(n＝20), and saline(n＝6). Heart rate decreased at 1 minute after the start of landiolol infusion and remained below pre-administration values(p<0.05) in patients receiving landiolol 40 and 80 μg/kg/min, while heart rate unchanged in control patients. Mean blood pressure remained unchanged as compared with pre-infusion values in all groups. When compared with the control group, heart rate was lower 5 and 4 minutes after the start of landiolol infusion(p<0.05) in patients given landiolol of 40 and 80 μg/kg/min, respectively.These data show that landiolol infusion at a rate of 80 μg/kg/min provided more rapid suppression of an abrupt tachycardia in patients undergoing total knee arthroplasty under general anesthesia. The prompt treatment of tachycardia by landiolol seems appropriate, particularly for the older patients who are likely to have occult ischemic heart disease.
A 60-year old man developed paraplegia three hours after thoracic endovascular aortic repair under general anesthesia for distal aortic arch aneurysm. This delayed-onset paraplegia was suspected to be due to a steal effect on the spinal small end arteries. The symptom was successfully alleviated by rapid lumbar cerebrospinal fluid drainage.
「ReDS (remote dielectric sensing) による肺水分量定量評価の妥当性の検証 - 心不全患者および非心不全患者における高分解能胸部断層撮影との比較」 Amir O, Azzam ZS, Gaspar T, Faranesh-Abboud S, Andria N, Burkhoff D, Abbo A, Abraham WT. Validation of remote dielectric sensing (ReDS(TM)) technology for quantification of lung fluid status : Comparison to high resolution chest computed tomography in patients with and without acute heart failure. Int J Cardiol 2016 ; 221 : 841-6. / 「心不全患者におけるPAPi (Pulmonary Artery Pulsatility Index) の予後への影響 - ESCAPE試験のデータを用いた検討」 Kochav SM, Flores RJ. Truby LK, Topkara VK. Prognostic Impact of Pulmonary Artery Pulsatility Index (PAPi) in Patients With Advanced Heart Failure : Insights From the ESCAPE Trial. J Cardiac Fail 2018 ; 24 : 453-9. / 「心収縮力の保たれた心不全に対する経カテーテル的心房間シャント作成術 (REDUCE LAP-HF I) 第二相無作為化偽手術対照比較試験」Feldman T, Mauri L, Kahwash R, Litwin S, Ricciardi MJ, van der Harst P, Penicka M, Fail PS, Kaye DM, Petrie MC, Basuray A, Hummel SL, Forde-McLean R, Nielsen CD, Lilly S, Massaro JM, Burkhoff D, Shah SJ, REDUCE LAP-HF I Investigators and Study Coordinators. Transcatheter Interatrial Shunt Device for the Treatment of Heart Failure With Preserved Ejection Fraction (REDUCE LAP-HF I [Reduce Elevated Left Atrial Pressure in Patients With Heart Failure] ) : A Phase 2, Randomized, Sham-Controlled Trial. Circulation 2018 ; 137 ; 364-75.
「院外心停止症例に対するエピネフリンの効果 : ランダム化比較試験」 Perkins GD, Ji C, Deakin CD, et al : A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med 2018 ; 379 : 711-21. / 「高齢慢性心不全患者における初回心不全入院治療の予測因子としての活性酸素代謝産物検査の有用性」 Hitsumoto T : Efficacy of the reactive oxygen metabolite test as a predictor of initial heart failure hospitalization in elderly patients with chronic heart failure. Cardiol Res 2018 ; 9 : 153-60. / 「集中治療を受けていない糖尿病患者に対するクローズドループインスリン療法」 Bally L, Thabit H, Hartnell S, et al. : Closed-loop insulin delivery for glycemic control in noncritical care. N Engl J Med 2018 ; 379 : 547-56.