Yoshihiro Takasugi

Mesenteric venous thrombosis in a patient with congenital afibrinogenemia and diffuse peritonitis

Congenital afibrinogenemia is a rare autosomal recessive hemorrhagic disorder, and thrombotic complications occurring spontaneously or after infusion of fibrinogencontaining preparations have been reported in afibrinogenemic patients [1]. We report a case of mesenteric venous thrombosis due to fibrinogen replacement in a patient with congenital afibrinogenemia. A 19-year-old male with congenital afibrinogenemia had previously undergone uneventful surgical procedures for splenic rupture, intracranial bleeding, and mandibular abscess (2002) with preoperative supplement of fibrinogen concentrate. He was urgently admitted to the Critical Care Medical Center and diagnosed with diffuse peritonitis in 2003. After prophylactic administration of ten units of fresh-frozen plasma (FFP), resection of the small intestine was performed. Numerous thromboses were detected in the mesenteric veins of the resected specimen. The color of the remaining small intestine darkened during wound closure and mesenteric circulation worsened. Continuous infusion of unfractionated heparin (Novo Heparin 1000, Mochida Pharmaceutical Co., Japan) at 500 units/h was initiated following a 2000-unit bolus. The following day, massive resection of the small intestine, leaving only 60 cm of small intestine, was performed due to necrosis identified during a second-look operation. In 2004, emergency surgery was performed for adhesive intestinal obstruction without hemostatic complications by prophylactic administration of fibrinogen concentrate and unfractionated heparin. Perioperative laboratory data from 2002, 2003, and 2004 are shown in Table 1. In 2002, data revealed undetectable plasma fibrinogen levels by the functional assay, undetectable prothrombin time (PT) and activated partial thromboplastin time (APTT), and thrombocytosis. Supplementation with 9000 mg of fibrinogen raised fibrinogen levels to 1.91 g/l and normalized PT and APTT. In 2003, fibrinogen levels, PT, APTT, and platelet count after preoperative administration of ten units of FFP were approximately the same as in 2002. However, excessively high levels of hemostatic and inflammatory markers preoperatively indicated a hypercoagulable and inflammatory state. While perioperative heparin infusion in the first operation suppressed levels of hemostatic markers, the levels of those in the second-look operation were still above normal range. In 2004, preoperative tests again showed undetectable plasma fibrinogen level and PT, but APTT was normal. Values for all hemostatic markers, WBC, and C-reactive protein (CRP) were markedly elevated compared to reference ranges, but platelet count was normal. Supplementation with fibrinogen concentrate and intraoperative heparin administration resulted in a plasma fibrinogen concentration of 1.03 g/l and an APTT of 44.7 s. Fibrinogen level measured using both functional and immunological assays was 0.1 g/l at 5 days after administration of 1000 mg of fibrinogen concentrate. Prothrombin activation increases and increased thrombin generation has been observed in afibrinogenemia [2]. Thrombin represents a potent activator of platelets and platelet aggregation [3]. Tefferi et al. [4] reported marked thrombocytosis occurring in 22.0% of postsplenectomy patients. Furthermore, Remijn et al. [1] showed that the absence of fibrinogen results in large but loosely packed platelet aggregates and suggested that afibrinogenemic patients could be at risk for thrombosis. Thus, hypercoagulable states due to increased prothrombin activation and platelet aggregation may exist in our patient. Compensative reaction for severe intestinal inflammation and/or heparin-induced thrombocytopenia [5] may have been considerable for the reduced platelet count in 2004, Y. Takasugi (*) . Y. Shiokawa . R. Kajikawa . J. Oh . Y. Koga Department of Anesthesiology, Kinki University School of Medicine, 377-2 Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan e-mail: yoshihiro.takasugi@nifty.com Tel.: +81-72-3660221 Fax: +81-72-3660206

Difficult laryngoscopy caused by massive mandibular tori

Mandibular tori, defined as bony protuberances located along the lingual aspect of the mandible, are a possible cause of difficult intubation. We describe a case of mandibular tori that resulted in difficult intubation. A 62-year-old woman who had speech problems was diagnosed with mandibular tori, and was scheduled for surgical resection. On physical assessment, the patient had a class II Mallampati view and bilateral mandibular tori. Preoperative computed tomography images demonstrated that the bilateral mandibular tori arose from the lingual aspects of the second incisor to the first molar regions of the mandibular corpus, and occupied the floor of the mouth. In the operating room, anesthesia was induced with remifentanil and propofol. After complete paralysis was achieved, laryngoscopy was attempted several times with Macintosh blades. The massive tori prevented insertion of the tip of the blade into the oropharynx, and neither the epiglottis nor the arytenoids could be visualized, i.e., Cormack and Lehane grade IV. Blind nasotracheal intubation was successful and the surgery proceeded uneventfully. The anesthesiologist should examine any space-occupying lesion of the oral floor and should be vigilant for speech problems in order to detect mandibular tori that might impede intubation.

Three-dimensional CT image analysis of a tracheal bronchus in a patient undergoing cardiac surgery with one-lung ventilation

AbstractThe incidence of a tracheal bronchus—that is, a congenitally abnormal bronchus originating from the trachea or main bronchi–is 0.1%–2%. Serious hypoxia and atelectasis can develop in such patients with intubation and one-lung ventilation. We experienced a remarkable decrease in peripheral oxygen saturation (

Tracheal intubation in a patient with undetectable tracheal narrowing on chest radiography.

Sp_{O_2 }

Suppression of the descending inhibitory pathway by continuous thoracic intrathecal lidocaine infusion reduces the thermal threshold of the tail-flick response in rats

) and a rise in airway pressure during placement of a double-lumen endobronchial tube in a patient with patent ductus arteriosus and tracheal bronchus. Substitution of the double-lumen tube with a bronchial blocker tube provided secure isolation of the lung intraoperatively. A type I tracheal bronchus and segmental tracheal stenosis were identified on postoperative three-dimensional (3D) computed tomographic (CT) images. Preoperative examination of chest X-rays, CT images, and preoperative tracheal 3D images should preempt such complications and assist in securing safe and optimal one-lung ventilation.

Roles of endotracheal tubes and slip joints in respiratory pressure loss: a laboratory study

OBJECTIVE The objective of this study was to investigate the role of periodontal pathogens in RA in remission. METHODS Twenty-one patients with active RA and 70 patients in clinical remission, including 48 patients with synovitis [US power Doppler (USPD)(+) group] and 22 patients without synovitis [USPD(-) group] were clinically assessed by US. CRP, ESR, haemoglobin, MMP-3, RF and ACPA were measured. Antibody titres against four types of periodontal pathogen [Aggregatibacter actinomycetemcomitans, Eikenella corrodens (Ec), Porphyromonas gingivalis and Prevotella intermedia (Pi)] were analysed using ELISA. RESULTS Musculoskeletal US examination showed that 68.6% of patients with RA in clinical remission exhibited synovitis. CRP, ESR, haemoglobin, MMP-3 and RF levels in both the USPD(+) and USPD(-) groups were clearly lower compared with the RA group in non-remission. The IgG serum antibody titre against Ec in the non-remission RA(+) group was significantly greater than that in the USPD(+) group, and the IgG antibody titre against Pi in the non-remission RA and USPD(+) groups was greater than in the USPD(-) group. CONCLUSION More than half of RA patients in remission showed persistent synovitis. This synovitis may be associated with periodontal disease-causing Pi. Thus, treating periodontal disease should also be considered in order to achieve more profound remission of RA.

Asymptomatic hemilateral pneumothorax and pneumomediastinum following surgical tracheostomy in a patient with hyponatremia and zolpidem withdrawal delirium

We report here a 59-year-old man with a saber-sheath tracheal narrowing who was scheduled to undergo pharyngeal tumor resection under general anesthesia. The tracheal narrowing was not clearly detected by chest radiography during the preoperative examination, but it was visible on axial computed tomography (CT) images taken earlier for diagnostic purposes. Following fiber optic examination of the narrowed segment with the patient under anesthesia, the tube was inserted into the trachea using an Airway Scope. The tube was deliberately advanced into the trachea and was able to pass through the stenosis without any resistance. On postoperative radiological analysis, three-dimensional reconstruction of the trachea and virtual bronchoscopic images revealed a saber-sheath type tracheomalacia located from below the cricoid cartilage to the carina. The membranous wall had a normal width. This case indicates that chest radiographs may occasionally be inadequate for evaluating asymptomatic patients with tracheomalacia. If CT images have been taken for diagnostic purposes, they should be examined together with the chest radiograph. Digital chest radiography with edge enhancement may become a useful tool in the preoperative detection and evaluation of undetectable tracheal narrowing on conventional chest films.

Thermophysical Properties of Thermosoftening Nasotracheal Tubes

Transient sensory disturbances, including dysesthesia or neurologic deficits in the lower extremities or buttocks have been described as complications of neuraxial anesthesia. We report a case of transient lower limb pain following the accidental placement of an epidural catheter into the thoracic subarachnoid space. A 31-year-old woman was scheduled to undergo laparoscopic myomectomy. An epidural catheter was accidentally inserted subarachnoid at the T12–L1 intervertebral space with a 2-ml test dose of 2% lidocaine, and was promptly removed. Fulgurant pain and allodynia extending over the L2–5 areas of the left lower limb and buttock started immediately postoperatively. We treated the persistent pain in our patient with epidural infusion of local anesthetics and steroids during her hospital stay, and with carbamazepine and a tricyclic antidepressant after her discharge from the hospital. All signs of allodynia had disappeared on postoperative day 25. Sagittal and axial T2-weighted magnetic resonance imaging (MRI) at the Th12 level revealed a small high-intensity area without mass effect in the ipsilateral dorsal column. The patient’s clinical course and MRI diagnosis suggested the inhibition of descending inhibitory pathways resulting from a lesion of the spinal cord as the possible etiology of the transient lower limb pain and allodynia.