Ryu Okutani

Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing One-Lung Ventilation

OBJECTIVES To investigate the ability of stroke volume variation (SVV) calculated by the Vigileo-FloTrac system (Edwards Lifescience, Irvine, CA) to predict fluid responsiveness in patients undergoing one-lung ventilation (OLV). DESIGN Prospective, observational study. SETTING Clinical hospital. PARTICIPANTS Thirty patients scheduled for a pulmonary lobectomy requiring OLV for at least 1 hour under combined epidural/general anesthesia. INTERVENTIONS After starting OLV, hydroxyethyl starch, 500 mL, was administered for 30 minutes. MEASUREMENTS AND MAIN RESULTS Hemodynamic variables including heart rate, mean arterial pressure, cardiac index, stroke volume index (SVI), and SVV were measured before and after volume loading. SVV before volume loading was significantly correlated with the absolute changes in SVV (ΔSVV) and percentage changes in stroke volume index (ΔSVI) after volume loading (ΔSVV: p < 0.05, r = -0.893; ΔSVI: p < 0.05, r = 0.866). Of the 30 patients, 15 (50%) were responders to intravascular volume expansion (an increase in SVI ≥ 25%), and 15 (50%) were nonresponders (an increase in SVI <25%). The area under the ROC curve was 0.900 for SVV (95% confidence interval, 0.809-0.991), whereas the optimal threshold value of SVV to discriminate between responders and nonresponders was 10.5% (sensitivity: 82.4%, specificity: 92.3%). CONCLUSIONS The authors found that SVV measured by the Vigileo-FloTrac system was able to predict fluid responsiveness in patients undergoing surgery with OLV with acceptable levels of sensitivity and specificity.

Effect of Hypothermic Hemodilutional Cardiopulmonary Bypass on Plasma Sufentanil and Catecholamine Concentrations in Humans

The effect of hypothermic hemodilutional cardiopulmonary bypass (CPB) on plasma sufentanil and catecholamine concentrations was studied in four groups of ten patients each, receiving four different doses of sufentanil. Samples for measurement of sufentanial were obtained before CPB, at 15, 30, and 45 minutes of CPB, during rewarming, immediately after and 15, 60, and 240 minutes after CPB. In addition, in groups III and IV, which received the highest dose of sufentanil, blood samples were also obtained for measurement of plasma levels of epinephrine and norepinephrine. Sufentanil concentration decreased in all groups with the start of CPE (group I, 2.92 ± 0.2 to 2.04 ± 0.2; group II, 3.30 ± 0.3 to 1.51 ± 0.2; group III, 7.08 ± 0.7 to 3.45 ± 0.3; group IV, 10.33 ± 0.5 to 4.59 ± 0.5 ng/ ml). No further decreases occurred during CPB but increases occurred with rewarming. The first measurement after CPB approached the concentration before CPB (group I, 2.82 ± 0.3; group II, 2.56 ± 0.5; group III, 4.42 ± 0.4; group IV, 6.10 ± 0.4 ng/ml). Norepinephrine concentrations demonstrated a wide variability with no significant changes. Epinephrine levels increased significantly during rewarming in both groups (group III, 141 ± 23 to 279 ± 79 pg/ml; P < 0.05; group IV, 105 ± 24 to 267 ± 68 pg/ml, P < 0.05). The stability of plasma sufentanil concentrations during CPB suggest that no measureable metabolism or excretion occurred. The increase with rewarming and after CPB suggest significant sequestration. The increase in plasma epinephrine levels with rewarming, when sufentanil concentrations were also increasing, make it unlikely that any clinically acceptable concentration of sufentanil is capable of preventing this response.

Hemodynamics in the prone jackknife position during surgery

We examined the hemodynamic changes occurring with prone jackknife positioning during colorectal surgery. The operative procedure was restorative proctocolectomy with ileal J-pouch anal anastomosis in five patients with adenomatosis coli and six patients with ulcerative colitis and anoabdominal resection of the rectum with colonic J-pouch anal anastomosis in eight patients with rectal cancer. Nineteen patients (10 men and 9 women aged 41 +/- 19 years) were monitored with arterial and Swan-Ganz catheters during positioning. Measurements were obtained in the supine and prone positions (1 minute, 3 minutes), and the jackknife position (1, 3, 5, and 10 minutes), as well as before and after adoption of the Lloyd-Davies position (1, 3, 5, and 10 minutes). Turning the patient from the supine position to the prone position resulted in a significant decrease in the cardiac index (CI). However, following head-down rotation, the CI increased and returned to the value seen in the supine position (p less than 0.05). Heart rate (HR) slowed and mean arterial pressure (MAP) increased in the prone jackknife position. We concluded that the extent of the changes in cardiac function presented no serious problems.

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.

Anesthetic management using total intravenous anesthesia with remifentanil in a child with osteogenesis imperfecta.

In patients with osteogenesis imperfecta (OI), general anesthetic management should be carefully implemented in consideration of difficult intubation and the potential risks of cervical or mandibular fracture associated with tracheal intubation, bone fracture during postural changes, and respiratory dysfunction due to thoracic deformity. To prevent temperature elevation, moreover, many reports have recommended anesthetic management using total intravenous anesthesia (TIVA) rather than inhalation anesthetics, which contribute to temperature elevation. In an 8-year-old boy with type II (fatal type) OI (height, 81 cm; body weight, 12.4 kg), we performed general TIVA with remifentanil and propofol, using a laryngeal mask airway for airway management. All possible intra- and postoperative complications were effectively prevented, and the remifentanil requirement was high, as shown by a mean dose of 0.36 μg·kg−1·min−1.

Anesthesia in a patient with mucopolysaccharidosis type VI (Maroteaux–Lamy syndrome)

We report a case of anesthesia during surgery to enlarge the foramen magnum in a pediatric patient with an extremely rare form of mucopolysaccharidosis type VI (Maroteaux–Lamy syndrome). Airway control was unexpectedly easy, and intraoperative anesthetic management with total intravenous anesthesia went smoothly. However, the disease is progressive, with no guarantee that future anesthetic management of this patient will remain easy. If repeated surgery is required, thorough testing should be conducted over time to assess both airway and systemic complications. Nevertheless, we found that safe anesthetic management of affected patients is possible with anesthetics currently used in a clinical setting.

Utility of the ProSeal laryngeal mask airway creating a 90° angle with an intubating stylet

To the Editor: The ProSeal laryngeal mask airway (PLMA; LMA North America, San Diego, CA, USA) is equipped with a double cuff mechanism and can maintain a high seal pressure. Hence, positive-pressure ventilation can be safely performed through it. In addition, suction of gastric contents through the drain tube helps prevent aspiration. However, because of the large cuff size of the PLMA, the success rate of insertion at the first attempt is low and insertion time is prolonged [1]. These potential problems can be overcome by using an intubating stylet with the laryngeal mask airway (LMA). Yodfat [2] was the first to describe use of the intubating stylet with a Classic LMA (Classic) (Yodfat technique). Jaffe and Brock-Utne [3] then reported the modified Yodfat technique using a Classic LMA. Subsequently, in 2007, Lee [4] introduced a new technique using the PLMA. Lee’s modification is equipped with an intubating stylet, which is inserted in the airway tube of the Classic LMA, and in the drain tube of the PLMA. Here, we introduce a technique that is a further improvement on Lee’s technique with the PLMA. In the technique which Lee introduced, an intubating stylet was used to bend approximately 2 cm of the cuff tips of the PLMA anteriorly by 45 . However, when we tried this, the anteriorly bent PLMA was often difficult to insert in patients with narrow pharyngeal spaces. Therefore, we remodeled a PLMA with an intubating stylet (Sher-i-slip: 10Fr, Teleflex Medical, Research Triangne Park, NC, USA) with the same angulation as the Fastrach laryngeal mask airway (Fastrach LMA, North America, San Diego, CA, USA) advocated by the Yodfat technique (Fig. 1). We inserted our modified PLMA using the same insertion technique as the Fastrach LMA. We can now easily insert the PLMA with the curvature form fitted to this anatomy. Vaida and Yodfat [5] reported that the high success rate of insertion of the AMBU laryngeal mask airway is dependent on angulation by 90 of the part of the tube that is close to the junction of the tube and laryngeal mask. Besides the benefits of existence of a drain tube and high seal pressure with the styleted PLMA as compared with the Yodfat technique, an additional advantage of our technique is being able to insert the stylet up to just before the cuff tip. In the Yodfat technique using the Classic LMA, upward turning of the cuff tip may have occurred after inserting the styleted LMA, because the stylet was advanced only up to the orifice of the airway tube. Conversely, with our technique, proper positioning of the cuff tip of the PLMA can be better achieved. There is a commercially available PLMA introducer (LMA) that can also produce the same angulation of the Firstrach LMA. The introducer for PLMA insertion is molded to form a fixed shape. Because it is hard in shape, it might injure the laryngeal pharynx if inserted forcibly. Moreover, the tip of the introducer does not reach the cuff tip of the PLMA, which causes bending of the tip. When performing PLMA insertion using the intubating stylet, the success rate is speculated be higher than for PLMA insertion with the introducer, because the stylet can be transformed to fit the shape of the laryngeal pharynx of each patient and reaches the cuff tip. In general, we performed insertion of the PLMA using a standard method in which we provided guidance with a finger tip on the first try, regardless of predictable difficulties of insertion. For cases in which the second tries R. Okutani (&) S. Ogawa Department of Anesthesia, Osaka City General Hospital, l2-13-22, Miyakojima-hondori, Miyakojimaku, Osaka, Osaka 534-0021, Japan e-mail: ryu0909@kcat.zaq.ne.jp

Anesthetic considerations in 65 patients undergoing unilateral pneumonectomy: problems related to fluid therapy and hemodynamic control

STUDY OBJECTIVE To examine perioperative management and complications in patients undergoing pneumonectomy. DESIGN Observational cohort study. SETTING University-affiliated city hospital. MEASUREMENTS 65 patients who underwent unilateral pneumonectomy for resection of lung cancer between March 1997 and October 2007 were included in this study. Patients who underwent pneumonectomy were then classified into two groups: Group C patients had signs of postoperative acute right heart failure, and Group N patients had no signs of postoperative acute right heart failure. MAIN RESULTS In the pneumonectomy patients, extubation did not occur in 8 patients (12%) and postoperative death occurred in 4 patients (6%), compared with no such occurrences among patients who underwent lobectomy. Perioperative respiratory function was significantly lower in Group C (P < 0.05) than Group N. Fluid infusion volume, fluid balance volume, intraoperative total fluid balance, urine output volume, blood loss volume, blood transfusion volume, times of administration of vasopressors intraoperatively, and number of patients requiring intraoperative administration of catecholamines were significantly greater in Group C (P < 0.05) than Group N. CONCLUSIONS Fluid infusion volume, fluid balance volume, intraoperative total balance, blood loss volume, and blood transfusion volume were important intraoperative risk factors in the development of postoperative right-sided heart failure.

Improved oxygen delivery to the fetus during cesarean section under sevoflurane anesthesia with 100% oxygen.

AbstractPurpose. To assess the potential benefits of sevoflurane with 100% oxygen in cesarean section in terms of oxygen delivery to the fetus, neonatal depression, and uterine contractility. Methods. Thirty-six patients undergoing elective cesarean section were enrolled. After thiamylal induction, 0.7% sevoflurane–60% nitrous oxide–40% oxygen anesthesia was administered in group G1 (n = 9), and 1.7% sevoflurane–100% oxygen anesthesia was administered in group G2 (n = 9). Spinal anesthesia under oxygen nasal prong was used in group SP (n = 18). Results. At delivery, the Po2 values in the maternal artery and the umbilical vein and artery (MA, UV, UA) of group G2 (474 ± 50, 43 ± 9, 32 ± 9 mmHg, respectively) were significantly greater than those in groups G1 (228 ± 46, 31 ± 4, 23 ± 5 mmHg, respectively) and SP (147 ± 21, 30 ± 7, 18 ± 7 mmHg, respectively). The So2 in the UA of group G2 (56 ± 17 %) was also greater than that in groups G1 (34 ± 10 %) and SP (32 ± 10 %). The sevoflurane concentrations at delivery in the MA, UV, and UA in group G2 were almost threefold higher than those in group G1, whereas all the newborns in the three groups had Apgar scores of 8 or more at 5 min, and the intraoperative blood loss did not differ among the groups. Conclusion. Sevoflurane anesthesia with 100% oxygen in elective cesarean delivery improves oxygen delivery to the fetus without severe neonatal depression, prolonged uterine relaxation, or increased blood loss.

Anesthesia for aortic reconstruction in a child with PHACE syndrome.

PHACE syndrome is a neurocutaneous syndrome characterized by the association of large cutaneous hemangiomas and the cardiac and cerebral vascular anomalies. We report a 6-year-old female with PHACE syndrome presented with left facial hemangiomas, cystic lesion in the cerebral posterior fossa, coarctation of the aorta, aplasia of the left vertebral artery and stenosis of the left internal carotid artery. Surgical repair of the aorta with left heart bypass under beating heart was scheduled. We monitored regional cerebral oxygen saturation (rSO2) with infrared spectroscopy in order to detect cerebral hypoperfusion. A decrease of rSO2 ipsilateral to the cerebrovascular anomalies occurred during anastomosis of the aorta, which was treated by reducing the flow rate of left heart bypass and by increasing the inhalational oxygen concentration. As children with PHACE syndrome are frequently accompanied with cerebrovascular anomalies and at a risk of cerebral hypoperfusion, prevention of cerebral hypoperfusion is crucially important during general anesthesia.