Hideki Shimaoka

Blood Purification for Crush Syndrome

At least 372 people developed crush syndrome after they were injured by the Great Hanshin-Awaji Earthquake. Of these, 23 were transferred to Osaka City General Hospital from the disaster area. The serum creatinine kinase (CK) of each of the 23 patients exceeded 10,000 IU/L. Sixteen of these patients were treated with various methods of blood purification including hemodialysis (HD), plasma exchange (PE), and continuous hemodiafiltration (CHDF). The effectiveness on each method of blood purification was evaluated in this study based on the clearance of myoglobin and the length of time until recovery from acute renal failure (ARF). None of the patients died, and none suffered from ARF longer than 2 months. The length of time required for blood purification was significantly correlated with the serum CK and myoglobin levels on admission. The serum myoglobin levels decreased linearly regardless of the method of blood purification used. Our findings showed that the severity of ARF that occurred in association with crush injury was proportional to the amount of crushed muscle and that once ARF had developed, the clearance of myoglobin was not affected by any of the blood purification methods tested including HD, PE, and CHDF. Therefore, the method of blood purification employed for crush syndrome should be selected for its effectiveness in treating ARF, rather than the elimination of myoglobin.

Perioperative management of a neonate with Cantrell syndrome.

Cantrell syndrome is a congenital malformation with a pentalogy characterized by defects involving the abdominal wall, lower sternum, anterior diaphragm, and diaphragmatic pericardium, as well as congenital cardiac anomalies. We recently managed anesthesia in a patient with this syndrome and herein report our experience. The patient was a 14-day-old male neonate, who had been diagnosed with Cantrell syndrome, including ventricular septal defect, left ventricular diverticulum, abdominal wall defect, omphalocele, and sternal hypoplasia. Surgical interventions to close the ventricular septal defect, resect the left ventricular diverticulum, and close the omphalocele were scheduled. After cardiac surgery, the hernial contents were returned to their original compartment and, subsequently, an attempt was made to suture the abdominal wall. However, blood pressure fell markedly and the attempt was discontinued. The chest was left open postoperatively and the patient was transferred to the intensive care unit (ICU), during which time circulatory and respiratory management was very complex. Issues requiring particular attention in the management of anesthesia for patients with this syndrome include complications of diverse cardiac malformations, pulmonary hypertension, pulmonary hypoplasia, and respiratory and circulatory failure associated with increased intraabdominal pressure due to primary closure of the omphalocele. Accordingly, extreme caution must be taken to restore respiratory and circulatory control.

Cardiac arrest caused by rapidly increasing ascites in a patient with TAFRO syndrome: a case report

Thrombocytopenia, anasarca, fever, renal insufficiency, and organomegaly (TAFRO) syndrome is a newly defined systemic inflammatory disorder with gradual progression of symptoms. A 59‐year‐old man with fever and ascites of unknown cause developed sudden‐onset shock and respiratory failure in the general ward. Cardiac arrest immediately followed. Although he was resuscitated, frequent administration of adrenaline was required to maintain his blood pressure. His circulation was most effectively stabilized by drainage of fluid from his distended abdomen. The volume of discharged ascites reached 4,000 mL at that time, and several liters continued to be discharged for >1 month. The diagnosis of TAFRO syndrome was based on the clinical features and laboratory and histological findings.