Junji Egawa

Effects of anesthetics on early postoperative cognitive outcome and intraoperative cerebral oxygen balance in patients undergoing lung surgery: a randomized clinical trial

PurposeOne-lung ventilation (OLV) may impair cerebral oxygen balance and induce postoperative cognitive dysfunction (POCD). It is unclear whether the type of anesthetic influences the incidence of POCD in patients undergoing OLV. This prospective study compared the incidence of POCD and intraoperative cerebral oxygen desaturation in OLV patients anesthetized with propofol vs sevoflurane during lung surgery.MethodsThere were 148 participants enrolled in this study and randomized equally to either the propofol or the sevoflurane group. Anesthesia was maintained with either propofol or sevoflurane combined in both groups with fentanyl and epidural anesthesia. Regional cerebral oxygen saturation (rSO2), jugular bulb venous oxygen saturation (SjO2), and the incidence of cerebral oxygen desaturation (rSO2 or SjO2 < 50% or rSO2 < 80% of baseline) were measured during anesthesia. Cognitive function was assessed using seven neurocognitive tests two days preoperatively, five days postoperatively (primary outcome), and three months postoperatively. Bivariable and multivariable regression analyses were conducted to identify factors associated with POCD.ResultsRates of POCD did not differ statistically between groups five days postoperatively (propofol, 16/72 patients; sevoflurane, 24/72 patients; RR, 0.67; 95% CI, 0.39 to 1.15; P = 0.14) or three months postoperatively (propofol, 9/60 patients; sevoflurane, 12/58 patients; RR, 0.73; 95% CI, 0.33 to 1.59; P = 0.42). Only three subjects per group showed intraoperative cerebral oxygen desaturation. Multivariable regression analysis revealed older age as an independent predictor of POCD.ConclusionsNo statistically significant difference in the incidence of POCD could be detected between the sevoflurane and propofol anesthesia groups. Postoperative cognitive dysfunction was relatively frequent following OLV in both groups. (Registration number: UMIN 000002826).RésuméObjectifLa ventilation unipulmonaire (VUP) pourrait avoir un impact négatif sur l’équilibre d’oxygène cérébral et induire une dysfonction cognitive postopératoire (DCPO). Nous ne savons pas si le type d’agent anesthésique influence l’incidence de DCPO chez les patients recevant une VUP. Cette étude prospective a comparé l’incidence de DCPO et de désaturation peropératoire en oxygène cérébral chez les patients sous VUP anesthésiés avec du propofol vs du sévoflurane pendant une chirurgie pulmonaire.MéthodeAu total, 148 patients ont participé à cette étude et ont été randomisés en deux groupes égaux à recevoir du propofol ou du sévoflurane. L’anesthésie a été maintenue à l’aide de propofol ou de sévoflurane, et l’agent de choix a été combiné à du fentanyl et à une anesthésie péridurale dans les deux groupes. La saturation en oxygène cérébral régional (rSO2), la saturation en oxygène veineux au bulbe de la veine jugulaire (SjO2) et l’incidence de désaturation en oxygène cérébral (rSO2 ou SjO2 < 50 % ou rSO2 < 80 % par rapport aux valeurs de base) ont été mesurées pendant l’anesthésie. La fonction cognitive a été évaluée à l’aide de sept tests neurocognitifs deux jours avant l’opération, cinq jours après l’opération (critère d’évaluation principal) et trois mois après l’opération. Des analyses de régression bivariée et multivariée ont été réalisées afin d’identifier les facteurs associés à une DCPO.RésultatsD’un point de vue statistique, les taux de DCPO n’étaient pas différents entre les groupes à cinq jours postopératoires (propofol, 16/72 patients; sévoflurane, 24/72 patients; RR, 0,67; IC 95 %, 0,39 à 1,15; P = 0,14) ou à trois mois postopératoires (propofol, 9/60 patients; sévoflurane, 12/58 patients; RR, 0,73, IC 95 %, 0,33 à 1,59; P = 0,42). Seuls trois patients par groupe ont manifesté une désaturation peropératoire en oxygène cérébral. L’analyse de régression multivariée a révélé qu’un âge avancé était un prédicteur indépendant de DCPO.ConclusionAucune différence significative d’un point de vue statistique n’a été observée en ce qui a trait à l’incidence de DCPO entre les groupes anesthésiés au sévoflurane ou au propofol. La dysfonction cognitive postopératoire était relativement fréquente après une VUP dans les deux groupes. (Numéro d’enregistrement: UMIN 000002826).

Two cases in which the effectiveness of “laryngospasm notch” pressure against laryngospasm was confirmed by imaging examinations

We report two cases in which development of laryngospasm and release of the spasm immediately after applying pressure in the “laryngospasm notch” was confirmed by ultrasonographic and fiberoptic examinations. A bronchoscopy was planned under propofol sedation using a laryngeal mask airway for a 61-year-old man after subtotal esophagotomy. When a bronchoscope was advanced into the trachea, the vocal cords suddenly closed. Immediately after pressure with the fingertips was applied to the “laryngospasm notch,” the vocal cords opened, which was observed through the bronchoscope in real time. A 22-year-old woman presented for emergency caesarean section under general anesthesia. After the completion of the procedures, the patient was not yet following commands but her breathing was steady. Thus, extubation was performed; however, she began to display signs of respiratory stridor. An ultrasonographic examination revealed that the vocal cords were noted to close, which suggested that she was developing laryngospasm. With this diagnosis, pressure at the “laryngospasm notch” was applied. Immediately after this maneuver, the vocal cords opened. We reconfirmed that applying pressure in the “laryngospasm notch” was effective to release laryngospasm. Imaging studies, especially ultrasonographic examination, were useful for making the decision to apply pressure in the “laryngospasm notch.”

Life-threatening airway obstruction due to upper airway edema and marked neck swelling after labor and delivery

BACKGROUND AND OBJECTIVES Airway changes generally occur in normal gravidas; however, these changes could cause critical situations in specific populations. OBJECTIVES This article presents the case of a difficult airway patient that went into shock because of atonic bleeding after vaginal delivery for stillbirth. CASE REPORT A 32-yr-old woman with atonic bleeding after vaginal delivery for stillbirth was transferred to our hospital. She manifested shock, and her respiratory condition was progressively deteriorating. Airway obstruction caused by neck swelling and pharyngolaryngeal edema was apparent. We tried tracheal intubation using direct and indirect laryngoscopes. However, it turned out that insertion of the laryngoscopic devices to the oral cavity was impossible. After several attempts using the Trachlight™, successful intubation was finally made. After hysterectomy, she was admitted to the intensive care unit (ICU) and treated for five days. At discharge from the ICU, her Mallampati score was I-II. Her body weight decreased 60 kg to 51 kg during ICU stay. CONCLUSIONS We believe that concomitant attacks of labor and delivery and fluid resuscitation probably worsened upper airway and neck edema enough to cause acute airway obstruction and difficult laryngoscopy.

Pulmonary hypertension due to unknown causes in liver resection

A 16-year-old male underwent transcatheter arterial embolization against a large hepatic tumor, and was subsequently scheduled for removal of the tumor. Sudden hypotension and tachycardia were observed on removal of the tumor. Massive bleeding or obstruction of the inferior vena cava was expected to develop, but this did not occur because of simultaneous pulmonary hypertension (PH). The development of acute PH due to pulmonary vasoconstriction was suspected. Milrinone and prostaglandin E1 were effective. The same type of PH was again observed during manipulation of the residual portion of the liver. The acute PH was reproducible each time the liver was manipulated, which could suggest that this series of PH was specifically related to the hepatic lesion. A necrotic hepatic lesion might play an important role in disturbing the pulmonary circulation and causing the development of acute PH.