Shuya Kiyama

Tension pneumothorax resulting in cardiac arrest during emergency tracheotomy under transtracheal jet ventilation.

A 48-year-old man was admitted because of severe dyspnea. The patient was in a healthy condition until one week before, when he noticed dyspnea on exertion. He had a history of thyroid papillary adenocarcinoma for which he had undergone right thyroid lobectomy 10 years ago. After that, tumorectomy for local recurrence has been performed for three times. On admission, he was severely dyspneic with peripheral cyanosis and remarkable stridor. Arterial blood gas analysis in room air showed compensated respiratory acidosis with pH of 7.41, Pao2 of 54 mmHg, and Paco2 of 57 mmHg. His hemoglobin was 14.9 g·dl1 . Chest X-ray revealed severe tracheal stenosis

Continuous spinal anesthesia and postoperative analgesia for elective cesarean section in a parturient with Eisenmenger's syndrome

We describe the use of continuous spinal anesthesia (CSA) for an elective cesarean section in a 29-year-old parturient with Eisenmenger’s syndrome at 30 weeks of gestation. It is essential in patients with Eisenmenger’s syndrome to prevent significant increases in right-to-left shunt following the reduction in systemic vascular resistance. In this case, the patient hoped to be awake during the operation because of her fear of death. We therefore applied CSA to this patient because single-shot spinal anesthesia and epidural anesthesia might cause sudden cardiovascular depression. In fact, sudden cardiovascular changes were avoided by the titration of local anesthetics and the operation was uneventful, although prompt treatment of hypotension was essential and adjustment of the anesthetic levels was difficult. Postoperative patient-controlled spinal analgesia provided satisfactory pain relief with hemodynamic stability and no significant side effects. However, thorough experience with the requisite techniques is critical in CSA because of the technical difficulty of the procedure, and anesthesiologists must gain such experience in less-demanding cases before attempting to administer it in patients presenting extreme challenges as described in this case report.

Application of gum elastic bougie to nasal intubation.

Gum elastic bougie (GEB), a useful device for difficult airway management, has seldom been used for nasotracheal intubation. Among 632 patients undergoing dental procedures or oral surgery, GEB was used successfully in 16 patients in whom conventional nasal intubation had failed because of anatomical problems or maldirection of the tip of the tracheal tube. We recommend that GEB should be applied from the first attempt for nasal intubation in patients with difficult airways.

Emergency laparotomy in uncontrolled thyrotoxic patient with preoperative fulminant hepatic failure

Acute stress of anesthesia and surgery can precipitate thyroid crrsis postoperatively in uncontrolled thyrotoxic patients. Preexisted liver dysfunction may also be aggravated in the postoperative period. V ncontrolled thyrotoxic patient developed fulminant hepatic failure, and during the course she suffered acute panperitonitis due to upper gastrointestinal tract perforation and underwent emergency laparotomy. We describe our perioperative management of this patient.

Titration of propofol infusion using processed electroencephalogram during combined general and spinal anesthesia

PurposeTo determine the necessary mean infusion rate of propofol during combined nitrous oxide (N2O) and propofol spinal anesthesia by using the processed electroencephalogram (pEEG).MethodsTwelve elective gynecological patients were monitored by a Dräger pEEG monitor under N2O and propofol spinal anesthesia. To make it easier to detect an inadequate depth of anesthesia, muscle relaxants were not given and the patients breathed spontaneously through a laryngeal mask airway. Manual step-down infusion of propofol was employed to provide intraoperative hypnosis. Propofol infusion was titrated to maintain cardiorespiratory parameters within 20% of baseline and the 90th percentile of the spectral edge frequency (SEF 90) of the pEEG between 10 and 13.5 Hz.ResultsThe mean (SD) induction dose of propofol was 2.9 (0.4) mg·kg−1. The mean (SD) maintenance infusion rate was 4.2 (0.5) mg·kg−1·h−1. The mean (SD) time from the end of propofol infusion to the opening of the patients eyes was 5.4 (2.0) min. No gross movements or intraoperative awareness was recognized. The mean (SD) SEF 90 during the maintenance of anesthesia was 12.2 (1.5) Hz, which increased significantly to 16.2 (1.9) Hz at 1 min before the patients opened their eyes in reponse to verbal commands.ConclusionTitration of propofol infusion using SEF during combined general and spinal anesthesia provided a rapid recovery without any clinical signs of inadequate anesthesia.

Refractory atrial fibrillation in an emergency surgical patient: a sign of untreated thyrotoxicosis

The patient was a 63-year-old woman who presented for emergency exploratory laparotomy due to acute abdominal pain. She had had an uneventful general anesthetic for lumbar laminectomy 5 years previously. She had not been on any medications except for an analgesic for her lumbago. She could not give any further medical history because of abdominal pain, dyspnea, and acute distress. Her peripheral pulse was irregular and her respiratory rate was 40 breaths per minute. Preoperative electrocardiogram showed atrial fibrillation with a rapid ventricular response, which had been unresponsive either to digoxin 0.25 mg or to verapamil 5 mg, i.v. Her temperature was 38.9~ and a surgeon attributed pyrexia to peritonitis. Goiter was not palpable. An interview with the patients family revealed that the patient had been experiencing finger tremor for the

Cardiac arrest and rhabdomyolysis after succinylcholine in a healthy child

Intractable, unexpected cardiac arrest following use of succinylcholine has been reported in children who are apparently in good health preoperatively. Most of these patients were boys who were subsequently found to have occult myopathies, primarily Duchennes muscular dystrophy [1-7]. Some, if not most, of these patients developed clinical signs compatible with malignant hyperthermia (MH). We report a case of sudden cardiac arrest after administration of succinylcholine, followed by severe rhabdomyolysis without hyperthermia, in a healthy girl. Possible association with MH is discussed.