Akimasa Miyata

Continuous haemodiafiltration during and after cardiopulmonary bypass in renal failure patients

PurposeContinuous haemodiafiltration (CHDF) is a technique enhancing the efficiency of solute clearance of continuous haemofiltration by infusing dialysis fluid through the haemofilter. It has been reported to control water and electrolyte balance continuously without haemodynamic instability in critically ill patients with renal failure. Therefore, we used CHDF during and after cardiopulmonary bypass (CPB) in two renal failure patients, and discuss its efficacy.Clinical featuresThe first patient undergoing aortic valve replacement had dialysis-dependent renal failure. Chronic renal failure in the second patient undergoing mitral valve replacement and coronary revasculanzation was controlled preoperatively with diuretics. In both cases, CHDF was performed not only during CPB but also in the post-CPB period. Serum concentrations of potassium, urea and creatmine were well-controlled in spite of large amount of blood transfused in the post-CPB penod (1000 ml fresh blood and 400 ml fresh frozen plasma in the fist patient, and 1400 ml fresh blood in the second patient). There was no difficulty in haemostasis dunng the use of nafamostat mesilate as an anticoagulant to keep activated clotting time at about 150 sec for CHDF in the post-CPB period.ConclusionOur initial expenences of CHDF dunng and after CPB suggest that the technique provides excellent electrolyte, metabolite and fluid management for the cardiac patients with chronic renal failure. Combined with nafarnostat mesilate for anticoagulation, CHDF was simple and safe and did not increase the nsk of bleeding.RésuméObjectifLa technique de l’hémodiafittration continue (HDFC) permet d’améliorer la clairance du soluté d’hémofiltration continue en perfusant le liquide de dyalise à travers un hémofiltre. Cette technique pourrait contrôler l’équilibre hydroélectrolytique en continu sans provoquer d’instabilité hémodynamique chez les insuffisants rénaux graves. L’utilisation de l’HDFC chez deux insuffisants rénaux pendant et après la circulation extracorporelle (CEC) nous offre l’occasion d’en discuter l’efficacité.Éléments cliniquesLe premier patient opéré pour un remplacement valvulaire aortique souffrait d’une insuffisance rénale nécessitant dyalise. L’insuffisance rénale chronique du deuxième patient soumis à un remplacement valvulaire mitral et à une chirurgie de revascularisation myocardique était contrôlée en préopératoire par des diurétiques. Dans les deux cas. nous avons utilisé l’HDFCnon seulement avant mais aussi après la CEC. Nous avons réussi à contrôler les concentrations sériques du potassium, de l’urée et de la créatinine malgré les grandes quantités de sang transfusées à la pénode post-CEC (l 000 ml de sang frais et 400 ml de plasma frais congelé pour le premier patient et l 400 ml de sang frais pour le second patient). L’hémostase s’est maintenue pendant l’anticoagulation au mésilate de nafamostat administré à la pénode post-CEC de façon à conserver sous HDFC un temps de coagulation à 150 s environ.ConclusionNos essais initiaux avec l’HDFC suggèrent que cette technique procure un excellent contrôle hydroélectrolytique et métabolique chez le patient cardiaque atteint d’insuffisance rénale chronique. Associée au mésilate de nafamostat pour I anticoagulation. l’HDFC s’est avérée sécuritaire et n’a pas augmenté le nsque de saignement.

Acute inhalational exposure to chlorodifluoromethane (freon-22): a report of 43 cases.

We report 43 cases of chlorodifluoromethane (Freon-22) intoxication that occurred on August 5, 2003 when a freezer in a seafood factory exploded. In this accident, 80 workers were exposed to Freon-22 gas and 43 workers developed symptoms and were transferred to six hospitals. Neurological symptoms including dizziness, headache, and nausea were most frequently observed (40 of 43 patients). One patient was comatose but recovered within 1 h with oxygen inhalation. Airway and respiratory symptoms including dysesthesia of the tongue, pharyngitis, and shortness of breath were also frequently observed (26 of 43 patients). These symptoms disappeared within a few days in all patients. There were no fatalities. Although Freon-22 has been considered to be a chlorofluorocarbon of relatively low toxicity, this incident suggests that potentially significant toxic effects may occur following large exposures.

Syndrome of inappropriate secretion of antidiuretic hormone associated with paroxetine

A 71-year old man with failed back syndrome was admitted to hospital with oliguria that had occurred 4 days after his dose of paroxetine had been increased to 40 mg·day−1. Laboratory data on admission revealed hyponatremia (124 mmol·l−1), low serum osmolarity (267 mOsm·l−1) with a normal level of serum antidiuretic hormone (1.7 pg ·ml−1), and concentrated urine (430 mOsm·l−1). He was diagnosed as having syndrome of inappropriate secretion of antidiuretic hormone, associated with paroxetine; this drug was discontinued immediately after admission. The hyponatremia was treated with saline infusion, water restriction, and furosemide; serum sodium level returned to normal on hospital day 5. Paroxetine is being increasingly used for depression and chronic pain management because of its favorable side-effect profile; however, we should be alert to hyponatremia in patients on paroxetine by carrying out periodic monitoring of serum electrolytes, especially in elderly patients.

Life-threatening spontaneous hemothorax in a patient with thrombotic thrombocytopenic purpura

Spontaneous hemothorax in the left pleural space occurred suddenly in a patient with thrombotic thrombocytopenic purpura (TTP). In spite of massive blood transfusion, the hemorrhage could not be stopped. The patient suffered shock due to tension hemothorax and hypovolemia, resulting in cardiac arrest. After successful cardiopulmonary resuscitation, surgical hemostasis was performed. The main cause of the bleeding was rupture of the left intercostal vein. TTP is a severe microvascular occlusive thrombotic microangiopathy that can induce congestion, vasculitis, and ischemia. This mechanism is thought to have been involved in the rupture of the intercostal vein in the present patient.

Successful use of Shakuyaku-kanzo-to, a traditional herbal medicine, for intractable symptoms of thoracic outlet syndrome: a case report.

Shakuyaku-kanzo-to (SKT) is a traditional herbal medicine that is widely used for muscular cramp and abdominal pain. We administered SKT for a patient with thoracic outlet syndrome (TOS) complaining of several resting symptoms. A 28-year-old female patient complained of intractable pain in the left arm, shoulder, and back and weakness, numbness, and muscular cramp in the left arm. She was diagnosed as TOS by digital subtraction angiography. Two days after the start of administration of SKT, her severe pain was markedly improved. Although numbness of the left arm was not improved, her overall pain score was reduced by 2 on the 7th day after the start of SKT. SKT has several pharmacological effects including analgesic and antiinflammatory effects, vasodilation, and muscle relaxation. Thus, our report suggests that SKT could be a first-line agent for the conservative treatment of TOS.

Middle-ear pressure variations during total intravenous anesthesia with propofol, fentanyl, and ketamine

PurposeAs the middle-ear cavity is one of the noncompliant gas-filled cavities, an increase in middle-ear pressure (MEP) instead of volume expansion is observed with inhalation of nitrous oxide (N2O). Changes in MEP cause many complications, such as ear pain, temporary hearing impairment, and postoperative emesis. Therefore, we investigated changes in MEP during total intravenous anesthesia (TIVA) with propofol, fentanyl, and ketamine (PFK) and inhalation of N2O.MethodsTwelve patients were anesthetized with PFK until 60 min after the induction of anesthesia, and then N2O (60%) inhalation was started. MEP was measured by impedance audiometry (ranging from −300 daPa to +200 daPa) at 10-min intervals during PFK, and at 2-min intervals after the inhalation of N2O.ResultsMEP gradually but significantly increased from the preanesthetic value of 16±8 to 34±12 (SEM) daPa 50 min after the induction of PFK. However, MEP did not exceed the normal limit. The values of MEP in all patients were more than 200 daPa within 36 min after the start of inhalation of N2O in oxygen.ConclusionPFK had a minimal effect on MEP, whereas addition of N2O to PFK increased MEP dramatically. Therefore, TIVA, or at least PFK, would be a better choice for patients with middle-ear or upper-airway diseases.