Katsunori Oe

Complete Heart Block during Anesthetic Management in a Patient with Mucopolysaccharidosis Type VII

IT is believed that complete heart block is unlikely to occur in patients without preexisting left bundle branch block. We describe the occurrence of complete heart block during attempted placement of a central venous catheter in a child with mucopolysaccharidosis (MPS) type VII (Sly syndrome) without preexisting left bundle branch block. Numerous reports of anesthesia in patients with MPS have described airway management and respiratory complications. However, cardiac problems during anesthesia in patients with MPS should he considered important because of the possibility of preexisting cardiomyopathy or coronary stenosis.

Relationship between adrenomedullin and vasopressin-aquaporin system under general anesthesia.

Aim: The roles of adrenomedullin (AM) in body fluid balance under general anesthesia were investigated. Methods: Time course changes in plasma osmolality, AM, arginine vasopressin (AVP), and urinary aquaporin 2 (AQP2) in 17 patients undergoing abdominal surgery under general anesthesia were examined. Results: Increases in plasma AM levels were observed in parallel with increases in the levels of urinary AQP2/creatinine (Cr) before induction and 90 and 180 min after initiation of anesthesia. Significant correlations between plasma AM and urinary AQP2/Cr (r = 0.62, p < 0.0001) as well as urinary AVP/Cr and AQP2/Cr (r = 0.60, p < 0.0001) were uncovered. Multivariate stepwise analysis identified plasma AM as the critical independent factor affecting urinary AQP2/Cr level. Conclusion: A novel correlation of AM and AQP2 which overlays an AVP-AQP2 system may play a key role in fluid homeostasis during general anesthesia.

Perioperative management of Fontan operation for two patients with arrhythmogenic right ventricular dysplasia.

to drug therapy and failed to respond to catheter ablation. In June 1996, the patient was admitted to the intensive care unit (ICU) of Okayama University Medical School for further management. On admission, frequent VT had caused marked right heart failure, and the central venous pressure (CVP) was approximately 20mmHg. The patient was immediately treated with flecainide acetate, cibenzoline succinate, and metoprolol tartrate. This was followed by transjugular ventricular pacing. However, the treatment was ineffective in reducing the frequency of VT. Subsequently, VT worsened, as manifested by the appearance of five types of VT of different origin and the persistent presence of VT 9 days after admission to the ICU. The patient developed marked right heart failure on day 10, which was treated by mechanical ventilation following intratracheal intubation. However, heart failure did not improve, and there was no increase in urine volume. Deterioration of right and left heart function was probably due to persistent VT and administration of antiarrhythmic agents. Therefore, 13 days after admission, intraaortic balloon pumping (IABP) was initiated. On the next day, percutaneous cardiopulmonary support (PCPS) was implemented. PCPS produced a rapid increase in urine volume and improved respiration but did not result in amelioration of VT. Accordingly, 16 days after admission, an emergency Fontan operation was performed. The patient was transferred to the operating theater, while IABP and PCPS were being applied. Anesthesia was mainly maintained with 43 μg·kg 1 fentanyl. When the large right atrium and right ventricle were resected under cardiopulmonary bypass, VT stopped and sinus rhythm appeared. A total cavopulmonary connection (TCPC)-type Fontan operation was performed (Fig. 1). The duration of cardiopulmonary bypass was 3h 19 min. Weaning from cardiopulmonary bypass was readily achieved by inducing mild hyperventilation and lowering arterial PCO2 to approximately 35 mmHg. At the same time, dopamine, dobutamine

Total spinal anesthesia provides transient relief of intractable pain.

PurposeIntentional total spinal anesthesia (TSA) has been used for intractable pain treatment. However, the long-term effect of pain-relief is controversial. We investigate the short- and long-term effects of pain-relief by TSA.MethodsTwelve patients with intractable pain participated in a crossover study. All participants received two different treatments in random order at a 30-day interval: iv infusion with 300 mg of lidocaine (iv-Lido), and TSA with 20 mL of 1.5% lidocaine (TSA-Lido). Pain level at rest was scored with the visual analogue scale (VAS: 0–100), and blood pressure and heart rate were measured before and at two hours, 24 hr, seven days, and 30 days after treatment. Plasma lidocaine concentrations were measured at 0.5, one, and two hours.ResultsHeart rate and mean arterial pressure during or after TSA-Lido were similar to those before TSA-Lido. Plasma lidocaine concentrations were similar between the two treatments. No significant difference in any value occurred in the iv-Lido treatment. VAS were similar before both treatments (87 ± 6 for TSA-Lido; 86 ± 7 for iv-Lido). After TSA-Lido, VAS decreased significantly until day seven (two hours, 17 ± 22,P < 0.01; 24 hr, 43 ± 20,P < 0.01; seven days, 66 ± 16,P < 0.01). However, VAS returned to the pre-block values 30 days after TSA-Lido.ConclusionIntractable pain was decreased significantly for several days after TSA, but pain-relief was not sustained.RésuméObjectifLa rachianesthésie totale (RAT) intentionnelle est utilisée comme traitement de la douleur irréductible même si son effet analgésique à long terme est controversé. Nous avons exploré les effets analgésiques de courte et de longue durée produits par la RAT.MéthodeDouze patients souffrant de douleurs rebelles ont participé à un essai croisé. Tous les participants ont reçu deux traitements différents, selon un ordre aléatoire, à 30 jours d’intervalle: une perfusion iv avec 300 mg de lidocaïne (Lido-iv) et une RAT avec 20 mL de lidocaïne à 1,5 % (Lido-RAT). Le niveau de douleur au repos a été coté selon l’échelle visuelle analogique (EVA: 0–100), et la tension artérielle (TA) et la fréquence cardiaque (FC) ont été mesurées avant, puis deux heures, 24 h, sept jours et 30 jours après le traitement. Les concentrations plasmatiques de lidocaïne ont été mesurées à 0,5, une et deux heures.RésultatsLa FC et la TAM, pendant et après la Lido-RAT, ont été similaires à celles d’avant la Lido-RAT. Les concentrations plasmatiques de lidocaïne ont été similaires pour les deux traitements. Aucune valeur n’a affiché de différence significative avec le traitement à la Lido-iv. Les cotes de l’EVA étaient comparables pour les deux thérapies (87 ± 6 avec la Lido-RAT et 86 ±7 avec la Lido-iv). Après l’administration de Lido-RAT, les résultats de l’EVA ont baissé significativement jusqu’au septième jour (deux heures, 17 ± 22,P < 0,01; 24 h, 43 ±20,P < 0,01; sept jours, 66 ± 16,P < 0,01). Toutefois, 30 jours après la Lido-RAT, les valeurs de l’EVA sont revenues à celles du pré-traitement.ConclusionLa RAT a permis de réduire significativement la douleur rebelle pendant quelques jours, mais cet effet analgésique n’a été que passager.

Anesthetic management of a patient with severe dilated cardiomyopathy and an automatic implantable cardioverter-defibrillator (AICD) during total gastrectomy

We report a case of severe dilated cardiomyopathy with an automatic implantable cardioverter-defibrillator (ICD) undergoing total gastrectomy. During the operation, the defibrillation function of the ICD was suspended and its pacing function was used solely in VOO mode. Electrodes of an external defibrillator were attached on the chest wall, and a pulmonary arterial (PA) catheter with a ventricle pacing port was inserted into the pulmonary artery. Proper perioperative management, including measures that the patient underwent the surgery uneventfully and could attain a rapid and successful discharge from the intensive care unit.