Takeo Suzuki

Anterior Thoracic Medial Block for Administering Postoperative Analgesia in the Internal Mammary Area.

(TTP) block, which can block many anterior branches of the intercostal nerve (Th 2–6). We have been able to relieve pain in the internal mammary region by performing the TTP. The combination of pectoral nerves block and TTP block enabled us to perform intraoperative management without general anesthesia for breast cancer surgery. However, there were a few breast cancer surgeries where the combination failed to relieve pain. In case 1, an 84-year-old woman with severe heart dysfunction had to undergo segmental resection at the upper outer region of her right breast. Considering potential postoperative respiratory complications, we performed pectoral nerves block (30 mL of 0.125% levobupivacaine) and TTP block (20 mL of 0.125% levobupivacaine) without general anesthesia. Fifteen minutes after applying these blocks, the analgesic range of the intercostal nerve from right Th2 to Th6 could be checked. The patient complained of pain at the right Th2 at the skin incision. The surgeon administered local infiltration anesthesia at the start of surgery, after which she did not complain of pain and breast resection was performed with no intraoperative problems. In case 2, a 66-year-old woman was scheduled to undergo segmental resection at the upper inner region of her right breast. She had undergone artificial dialysis 20 years before because of diabetic nephropathy. Considering the perioperative hemodynamics, we selected the same anesthesia as in case 1. Fifteen minutes after applying these blocks, the analgesic range from right Th2 to Th6 was checked. She complained of pain at the right Th2 at the skin incision. Therefore, we performed ultrasound-guided right cervical plexus block (5 mL of 2% mepivacaine). Five minutes after the block, she experienced pain relief and breast resection was performed with no intraoperative problems. The aforementioned results suggest that, in some cases of breast cancer surgery, a supraclavicular nerve block may be required along with a cervical plexus block.

Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor

BACKGROUND Mesenteric traction syndrome (MTS) develops in the early phase of laparotomy, which is triggered by pulling of the mesentery. We attempted to analyze the circulatory dynamics of MTS by using the FloTrac sensor. METHODS Prospective randomized control study, the MTS trial, was conducted with or without prophylactic administration of flurbiprofen axetil in order to control MTS development in 57 elective open colorectal surgeries. None of the Flurbipurofen group patients (n = 23) develop MTS and were allocated to the non-MTS group. Among the non-flurbiprofen group, 28 patients (82%) developed MTS and were categorized into the MTS group. For these patients, in addition to blood pressure, stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured by FloTrac sensor. RESULTS The lowest blood pressure was noted within 30 minutes from the beginning of the intra-abdominal examination; in the non-MTS group, the mean blood pressure decreased by 16.7%, and in the MTS group, it decreased by 34.2% (P < .01). SVV of the 28 MTS patients was as follows: <9% in 10 patients (35.7%), >9% and <13% in 8 patients (28.6%), and >13% in 10 patients (35.7%). SVRI rose in the non-MTS group by 5.1%, whereas it fell in the MTS group by 15.1% (P < .01), indicating the close relationship between MTS and SVRI. CONCLUSIONS The SVV results indicate that fluid loading is not that optimal treatment against hypotension of MTS and that it is also important to consider the use of a vasoconstrictor. FloTrac is therefore useful for making an appropriate decision on the treatment strategy for MTS.