Sho Carl Shibata

Continuous subcostal oblique transversus abdominis plane block provides more effective analgesia than single-shot block after gynaecological laparotomy: A randomised controlled trial.

The transversus abdominis plane (TAP) block provides good analgesia in patients after abdominal surgery. However, the duration of the single-shot TAP block postoperatively varies across studies. The duration of analgesia can be prolonged by adding a continuous local anaesthetic infusion. We conducted a prospective, randomised, controlled, observer-blinded trial to compare the efficacy of continuous TAP block and single-shot TAP block in patients undergoing elective open gynaecological cancer laparotomy.

Long-lasting effect of transcutaneous electrical nerve stimulation on the thermal hyperalgesia in the rat model of peripheral neuropathy

We demonstrate here unexpectedly long-lasting effect of transcutaneous electrical nerve stimulation (TENS) to alleviate thermal hyperalgesia in rats with peripheral neuropathy produced by constriction of sciatic nerve. For TENS groups, electrical stimulation for 16.7 min (1 Hz, paired current, 12 mA, 5-ms interval, 0.2-ms duration, 999 pairs), once a day, was delivered for 5 consecutive days, under halothane anesthesia (Hal-TENS group) or pentobarbital anesthesia (Pent-TENS group). For non-TENS groups, only the anesthesia was delivered (Hal-no TENS group, Pent-no TENS group). For the control group, neither anesthetics nor TENS was delivered. To evaluate hyperalgesia, paw withdrawal latency (PWL) to radiant heat was measured before nerve constriction and five times after the constriction; just before TENS and at 1, 3, 7, and 14 days after the completion of TENS. Compared to the non-TENS groups, rats in the TENS groups showed significantly reduced thermal hyperalgesia at least for 3 days (Pent-TENS group) or for 7 days (Hal-TENS group) after TENS. These results indicate a possible long-lasting therapeutic effect of TENS applied under general anesthesia.

Intraoperative Right Ventricular Fractional Area Change Is a Good Indicator of Right Ventricular Contractility: A Retrospective Comparison Using Two- and Three-Dimensional Echocardiography

OBJECTIVE Intraoperative two-dimensional echocardiography is technically challenging, given the unique geometry of the right ventricle (RV). It was hypothesized that the RV fractional area change (RVFAC) could be used as a simple method to evaluate RV function during surgery. Therefore, the correlation between the intraoperative RVFAC and the true right ventricular ejection fraction (RVEF), as measured using newly developed three-dimensional (3D) analysis software, was evaluated. DESIGN Retrospective study. SETTING University hospital. PARTICIPANTS Patients who underwent cardiac surgery with transesophageal echocardiography monitoring between March 2014 and June 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixty-two patients were included in this study. After the exclusion of poor imaging data and patients with arrhythmias, 54 data sets were analyzed. RVFAC was measured by one anesthesiologist during surgery, and full-volume 3D echocardiographic data were recorded simultaneously. The 3D data were analyzed postoperatively using off-line 3D analysis software by a second anesthesiologist, who was blinded to the RVFAC results. The mean RVFAC was 38.8% ± 8.7%, the mean RVEF was 41.4% ± 8.3%, and there was a good correlation between the RVFAC and the RVEF (r(2) = 0.638; p<0.0001). CONCLUSIONS The RVFAC was well-correlated with the RVEF calculated using 3D echocardiography; therefore, RVFAC provides a simple and useful method for anesthesiologists to evaluate intraoperative RV function.

Undiagnosed Thyrotoxicosis in a Pregnant Woman with Spontaneous Renal Artery Aneurysm Rupture

Renal artery aneurysm (RAA) rupture during pregnancy is a rare event which is associated with high mortality rates for both mother and fetus. Hyperthyroidism may be present during pregnancy. Both complications are easily confused with more common conditions. We report an unusual case of a pregnant woman with undiagnosed hyperthyroidism and spontaneous RAA rupture. Thyroid storm may have been precipitated by the RAA rupture; however, the diagnosis was delayed because signs and symptoms were mistaken for those of hypovolemia. The possibility of thyrotoxicosis should be considered when mental status changes and tachycardia persist after the treatment of hypovolemic shock.

Efficacy and Safety of Landiolol Compared to Amiodarone for the Management of Postoperative Atrial Fibrillation in Intensive Care Patients.

OBJECTIVE The authors assessed the efficacy and safety of landiolol, an ultra-short-acting beta-blocker, with those of amiodarone in the restoration of sinus rhythm for postoperative atrial fibrillation (POAF) in intensive care unit (ICU) patients. DESIGN A retrospective data analysis. SETTING Data were collected from patients admitted to the ICU in a single university hospital between 2012 and 2015. PARTICIPANTS Records of a total of 276 patients who developed POAF after ICU admission were collected from hospital records. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Treatment success was defined as restoration of sinus rhythm without concomitant therapy within 24 hours of treatment and lasting for more than an hour. The landiolol dosage was in the range of 0.7 µg/kg/min-to-2.5 µg/kg/min. The authors compared a total of 55 patients with POAF who received either landiolol (n = 32) or intravenous amiodarone (n = 23) in the ICU. The major findings were that the median time required for conversion to sinus rhythm was shorter in landiolol patients compared with amiodarone patients (75 v 150 min respectively, p = 0.0355). However, treatment success rates did not differ significantly after 24 hours (odds ratio 1.25, 95% confidence interval 0.17-9.09, p = 0.60). Adverse events with bradycardia leading to drug discontinuation were seen only in the patients receiving amiodarone (n = 3, p = 0.032). CONCLUSIONS Landiolol achieved swift and safe restoration of sinus rhythm in ICU patients with POAF and could be considered as a favorable drug choice over amiodarone in such patients.

Factors Related to the Severity of Early Postoperative Infection after Heart Transplantation in Patients Surviving Prolonged Mechanical Support Periods: Experience at a Single University

OBJECTIVE The authors examined the effect of prolonged support with continuous-flow ventricular assist devices (CF-VADs) and other related factors on the severity of infections within 30 days of heart transplantation (HTx). DESIGN A retrospective analysis of consecutive HTx procedures. SETTING University hospital, between 2010 and 2016. PARTICIPANTS A cohort of 53 heart transplantation recipients (median age, 38.5 yr; interquartile range [IQR], 30.3-49.2 yr; women, 34%). INTERVENTIONS Forty-nine patients required CF-VAD support (median duration, 946 d; IQR, 600-1,132 d). MEASUREMENTS AND MAIN RESULTS Severity of postoperative infections was categorized as follows: no infection, minor infection (resolved within 14 days), major infection (resolved after >14 days), and severe infection (septic shock). Results were expressed as number (frequency) and median with IQR. Potential risk factors for increased infection severity were expressed as odds ratio (OR) with 95% confidence interval (CI). Postoperatively, no infection, minor infection, major infection, and severe infection occurred in 32 (60.4%), 8 (15.1%), 8 (15.1%), and 5 patients (9.4%), respectively. Active ventricular assist device (VAD)-specific infections at the time of HTx occurred in 37.7% of patients. Moderate-to-severe primary graft dysfunction occurred in 26.4% of the patients. Multivariable analysis indicated that risk factors for increased infection severity included active VAD-specific infection (OR 4.8; 95% CI 2.3-11.2) and moderate-to-severe primary graft dysfunction (OR 8.8; 95% CI 2.1-42.5) but not duration of CF-VAD support (OR 1.0; 95% CI 1.0-1.0). CONCLUSION Active VAD-specific infection and poor graft function likely contribute to the severity of early postoperative infections after HTx.

Anesthetic Management of a Patient With a Biventricular Assist Device Who Was Scheduled for Aortic and Pulmonary Valve Closure.

From the Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan. Reprint requests to Yu Matsumoto, MD, Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. E-mail: y.matsumoto0611@gmail.com

Pain Management With Bilateral Continuous Thoracic Paravertebral Block in a Patient With Fontan-Associated Hepatocellular Carcinoma Undergoing Hepatectomy.

Objective We report a case of perioperative management of a single-ventricle patient with Fontan-associated liver disease undergoing hepatectomy. Case Report A 12-year-old boy with Fontan circulation was scheduled for partial hepatectomy to remove a liver mass in segment 6. He received stent implantation to relieve conduit stenosis 6 months before the operation. The operation was performed under general anesthesia and with a bilateral thoracic paravertebral block (PVB). A continuous paravertebral infusion of levobupivacaine was administered via right and left catheters postoperatively. He was hemodynamically stable throughout the perioperative period, extubated soon after surgery, and had an uncomplicated postoperative course. Conclusions An analgesic regimen including thoracic PVB resulted in a rapid recovery without opioid-related side effects and early reinitiation of anticoagulation therapy. Our case illustrates the effective application of thoracic PVB in congenital heart disease patients for non–cardiac-related surgery.

Unexpected bioprosthetic mitral valve thrombus during left ventricular assist device implantation

Acute bioprosthetic valve thrombosis can occur after surgery and sometimes cause hemodynamic instability and cardiogenic shock. Risk factors for bioprosthetic valve thrombosis are hypercoagulability, atrial fibrillation, atrial dilatation, low cardiac function, and lack of anticoagulation therapy. The authors present a case of severe mitral stenosis due to bioprosthetic valve thrombus. The patient was diagnosed with dilated-phase hypertrophic cardiomyopathy and underwent mitral valve replacement. He required venoarterial extracorporeal membrane oxygenation (VA-ECMO) due to extremely low cardiac output and was scheduled for left ventricular assist device (LVAD) implantation. Transesophageal echocardiographic examination before LVAD implantation revealed severe mitral stenosis due to bioprosthetic mitral valve thrombus, which was not detected by transthoracic echocardiography in the intensive care unit and contributed to the low cardiac function. The thrombus was removed through an unscheduled left atriotomy before LVAD implantation. The possibility of bioprosthetic valve thrombosis must be considered when the patient is dependent on VA-ECMO support. Early transesophageal echocardiographic examination of the bioprosthetic valve may be helpful and contribute to surgical decision-making.

Perioperative factors related to the severity of vocal cord paralysis after thoracic cardiovascular surgery: A retrospective review

BACKGROUND Vocal cord paralysis (VCP) is a rare complication of thoracic cardiovascular surgery. In severe cases, life-threatening airway obstruction may occur. OBJECTIVE To evaluate the incidence and severity of VCP among patients who underwent thoracic cardiovascular surgery and to identify possible risk factors. DESIGN Single-centre retrospective review of adult patients. SETTING Osaka University Hospital, Suita, Japan, from January 2013 to August 2015. PATIENTS We included 688 patients in the final analysis. Preoperative, intraoperative and postoperative data were collected from medical records. Patients with preoperative VCP or tracheostomy prior to extubation were excluded. The VCP severity in relation to functional recovery was graded using the following categories: absent; mild, remission at 6 months; moderate, partial or persistent VCP at 6 months; or severe, airway obstruction after extubation requiring reintubation. An otolaryngologist diagnosed all VCP cases. MAIN OUTCOME MEASURES The incidence and severity of VCP after extubation. RESULTS The incidence (number) of VCP was 4.7% (32), with those of mild, moderate and severe VCP being 1.7% (12), 1.5% (10) and 1.5% (10), respectively. The ICU stay was significantly longer in patients with severe VCP than in patients without VCP [12.5 days (interquartile range 5.5 to 25.5) vs. 3 days (interquartile range 2 to 5), P = 0.0002]. In our multivariable analysis, type 2 diabetes mellitus [odds ratio (OR) 1.853, P = 0.009], intubation period (OR per 24 h 1.136, P = 0.014), ascending aortic arch surgery with brachiocephalic artery reconstruction (OR 8.708, P < 0.001) and ventricular assist device implantation (OR 3.460, P = 0.005) were independent predictors for VCP. CONCLUSION The identification of these risk factors may facilitate screening for VCP before extubation and possibly help anaesthesia personnel to be prepared to treat VCP-related airway obstruction should it occur.