Kumiko Fujise

Catecholamine Release caused by Carbon Dioxide Insufflation during Laparoscopic Surgery

PURPOSE We evaluated plasma catecholamine levels during pneumoperitoneum in laparoscopic surgery. MATERIALS AND METHODS Plasma epinephrine and norepinephrine were evaluated in 29 patients who underwent laparoscopic retroperitoneal surgery in a half lateral decubitus position (group 1) or laparoscopic varicocelectomy in a Trendelenburg position (group 2). RESULTS The levels of epinephrine and norepinephrine increased significantly 5 minutes after carbon dioxide insufflation compared to levels after Veress needle insertion and just before insufflation. The elevation of catecholamine levels during laparoscopic procedures was greater in group 1. CONCLUSIONS Our results indicate that carbon dioxide insufflation may cause catecholamine release during laparoscopic surgery. Careful monitoring of hemodynamics is mandatory at the beginning of the procedure.

Orotracheal intubation through the laryngeal mask airway in paediatric patients with Treacher-Collins syndrome

The laryngeal mask airway (LMA) is useful as an airway intubator (conduit) for an intubating tracheal bougie or fibreoptic bronchoscope, over which a tracheal tube is passed. However, in our paediatric patients with Treacher‐Collins syndrome, only the latter technique was successful. This was attributed to the fact that a posteriorly protruded tongue displaced the LMA, made the glottis move considerably anterior and interfered with the attempts to enter the trachea with a bougie. Downward displacement of the epiglottis, which can sometimes impair the intubation technique through the LMA, was not observed in our patients. Partial obstruction of a tracheal tube within the LMA occurred in one of the patients.

The effects of the lateral position on cardiopulmonary function during laparoscopic urological surgery

Laparoscopic urological surgery is usually performed transperitoneally with retroperitoneal insufflation of carbon dioxide (CO2) in the lateral position.We studied whether a difference in the side of lateral position affected hemodynamic and pulmonary functions during pneumoperitoneum. Fifteen patients (eight in the right and seven in the left lateral position) undergoing elective laparoscopic urological surgery were studied under general anesthesia. Hemodynamic variables and blood gas data were recorded. Before insufflation, mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), central venous pressure (CVP), and pulmonary capillary wedge pressure (PCWP) in the right lateral position were higher than those in the left lateral position. Pneumoperitoneum increased MAP, MPAP, CVP, PCWP, and cardiac index but decreased systemic vascular resistance in the right lateral position. Similar changes occurred during pneumoperitoneum in the left lateral position, but the changes were less than those in the right lateral position. The respiratory index (PaO2/PAO2), intrapulmonary shunt, and SpO2 did not change during pneumoperitoneum in either lateral position. Changing the side of the lateral position affected hemodynamic function but did not affect pulmonary oxygenation during pneumoperitoneum. Implications: The right and left lateral positions produced different hemodynamic changes during laparoscopic urological surgery. The increases in preload and cardiac index and the decrease in systemic vascular resistance were greater in the right than in the left lateral position. Respiratory changes were not affected differently between the right and left lateral positions. (Anesth Analg 1998;87:925-30)

Laryngeal mask and tracheal stenosis

The use of the laryngeal mask with controlled ventilation in a child with tracheal stenosis has been published previously [I]. One of the disadvantages of using the laryngeal mask in this population is air leakage, as high inflation pressures may be required during controlled ventilation. We report a patient with tracheal stenosis in whom the laryngeal mask was successfully used by maintaining spontaneous breathing. A 49-year-old man was scheduled for wedge resection of a femoral head. Pre-operative chest X ray revealed a tracheal stenosis, starting at the level of the sternum and extending to the tracheal carina (Fig. 1). The narrowest calibre was about 8 mm. Computed tomography showed a deformed trachea, in which the coronal diameter was less than one half of the sagittal diameter. The diagnosis of ‘sabre-sheath’ trachea was made. Pulmonary function studies indicated obstructive airway disease with the ratio of FEV, to FVC of 53%; vital capacity was 87% of predicted. Analysis of arterial blood gases revealed Pao, 9.5 kPa, Paco, 5.8 kPa, and pH 7.4. Despite the tracheal stenosis, he had no symptomatic respiratory complications. Clear breath sounds were heard equally over both lung fields. No chest wall retraction was observed. At the preoperative consultation he strongly requested general anaesthesia during surgery. After epidural anaesthesia was established, general anaesthesia was induced by allowing the patient to inhale nitrous oxide, oxygen, and increasing concentrations of halothane up to 1.5%, supplemented with diazepam 2.5 mg. A size 3 laryngeal mask was easily inserted without interruption to spontaneous respiration. The correct position of the mask was confirmed by passing a fibreoptic bronchoscope down the lumen. During induction of anaesthesia and surgery the stenosis did not appear to worsen. End-expiratory carbon dioxide tension and arterial oxygen saturation were continuously within normal limits; analyses of arterial blood gases taken during surgery were also normal. After an uneventful intra-operative course, the laryngeal mask was removed without complications. ‘Sabre-sheath’ trachea is defined as a deformed trachea with an internal coronal diameter two-thirds of, or less than, its internal sagittal diameter only in the intrathoracic part of the trachea [2]. The deformed trachea is usually densely ossified and is unlikely to collapse. The advantages of maintaining spontaneous respiration over controlled ventilation are threefold: first, since the inflation pressures are negative during spontaneous inspiration, air leakage is unlikely to occur. Second, while air trapping might be a problem during controlled ventilation, this is likely to be mild during spontaneous respiration. Furthermore, if ventilation is controlled in patients with severe tracheal stenosis, turbulent flow will occur distal to the stenosis, Fig. 1. Postero-anterior view of a high kilovoltage film of the trachea showing marked coronal narrowing of the intrathoracic trachea with an abrupt return to normal at the thoracic inlet.

Anaesthesia for cardiac surgery in children with nemaline myopathy.

Nemaline myopathy is a rare congenital myopathy associated with skeletal deformities and respiratory complications. Three children with nemaline myopathy who underwent cardiac surgery are described where the heart rate decreased during induction of anaesthesia and body temperature increased during or after the surgery. The anaesthetic implications in the management of patients with nemaline myopathy are discussed.

Respiratory effects of CO2 pneumoperitoneum during transperitoneal laparoscopic urological surgery

OBJECTIVE To evaluate the effects of CO2 pneumoperitoneum on respiratory function during urological laparoscopic surgery with exposure of the retroperitoneal space in the lateral decubitus position. METHODS Arterial blood gas analysis and measurements of the partial pressure of CO2 in exhaled gas (PetCO2) were performed during CO2 pneumoperitoneum in 12 patients who underwent transperitoneal laparoscopic surgery for the retroperitoneal organs (the retroperitoneal group): the results were compared to those of 11 patients who underwent laparoscopic varicocelectomy (the varicocele group) with the same anesthesia and intra-abdominal pressure. RESULTS The increase in PaCO2 and PetCO2 and the decrease in arterial pH during CO2 insufflation were significantly greater in the retroperitoneal group than in the varicocele group. PaCO2, PetCO2 and arterial pH continued to change in the retroperitoneal group, whereas these values reached a plateau at 30 min after the beginning of CO2 insufflation in the varicocele group. CONCLUSIONS The respiratory effects of CO2 pneumoperitoneum are more pronounced during laparoscopic urological surgery with opening of the retroperitoneum. It is possible that exposure of the retroperitoneal space increased CO2 absorption during insufflation.

Damage to a syringe pump by propofol

already supported the use of heliumoxygen in asthma [4] and in respiratory obstruction when it was stated to be effective within minutes [5]. These authors both suggested further investigation should be encouraged. It is likely that helium-oxygen improves tidal flow, immediately assisting oxygenation and, possibly more importantly, facilitating elimination of carbon dioxide and reducing the extreme fatigue with imminent respiratory failure which can require intubation and positive pressure ventilation. Bronchodilators and anti-inflammatory drugs are not without problems, neither apparently is intravenous magnesium [6, 7]. Helium is known to be effective. Does this useful agent deserve to be abandoned?

Severe cardiovascular changes associated with pancuronium after cardiopulmonary resuscitation and after brain injury

Severe hypertension, tachycardia or ECG changes have been reported following i.v. administration of pancuronium to patients with pheochromocytoma or bronchial asthma. These cardiovascular changes were explained by an interaction between autonomic effects of pancuronium and elevated serum catecholamines or aminophylline. We noted similar cardiovascular changes associated with i.v. administration of pancuronium in two patients after successful cardiopulmonary resuscitation and in two with midbrain hemorrhage and epidural hematoma. In these patients, pancuronium produced no abnormal cardiovascular changes when given during elective surgery or before the occurrence of midbrain hemorrhage. Thus, ischemic brain damage may play a role in producing the severe cardiovascular changes associated with pancuronium.

A patient with cardiac amyloidosis successfully managed with propofol anesthesia.

The preoperative electrocardiogram (ECG) showed first degree AV block alone; the heart rate was 70– 80 min 1. Ultrasound assessment (UCG) showed a hypertrophied interventricular septum and a normal left ventricular ejection fraction of 68%, but left ventricular diastolic function was decreased on UCG. Pulse Doppler methods of UCG showed that the atrial peak velocity/early peak velocity (A/E) ratio was 1 (0.7) and the deceleration time (DT) was 190ms. These data suggested a pseudonormalization state. Although these data seemed to be normal, the diastolic function of the left ventricle had been progressively damaged. His cardiac symptoms were evaluated as New York Heart Association (NYHA) degree 2. Coronary angiography showed no abnormal findings. Blood chemistry showed slight elevation of blood urea nitrogen (BUN) (25 mgdl 1) and creatinine (1.2mgdl 1), which reflected renal amyloidosis. After premedication with 5mg of diazepam and 150 mg of ranitidine orally 1h before arrival at the operating room, anesthesia was induced with 70 mg of propofol, 100 μg of fentanyl, and 8 mg of vecuronium. Anesthesia was maintained with 4–5 mg·kg 1·h 1 of propofol and intermittent injections of fentanyl and vecuronium. His respiration was supported by ventilation with air and oxygen. Total doses of propofol and fentanyl were 863 mg and 250μg, respectively. In addition to basic monitoring, a cannula was inserted into the right dorsalis pedis artery, and a pulmonary artery (PA) catheter (Edwards Swan-Ganz CCO/ Sv̄O2/VIP Thermodilution Catheter 8 F, Baxter) was inserted in order to evaluate hemodynamic changes during the procedure. Intraoperative changes in hemodynamic variables are shown in Fig. 1. Because the cardiac index (CI), blood pressure, and pulmonary capillary wedge pressure (PCWP) decreased to 1.7 l·min 1·m 2, 78/46 mmHg, and 8mmHg, respectively, although the oxygen saturation in mixed venous blood (Sv̄O2) was within normal range