Yutaka Oda

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.

Anesthetic management in a child with Rolland-Desbuquois type dyssegmental dysplasia

A case of a 17-month-old boy with dissegmental dysplasia of the Rolland-Desbuquois type, who was scheduled for bilateral inguinal herniotomy, is presented. Preoperative assessment showed limited mouth opening, head extension, and kyphosis. Intubation with a size 4 mm endotracheal tube (ETT) was achieved with fiberoptic bronchoscopy, after which surgery proceeded uneventfully and the ETT was carefully removed. Copious airway secretions required frequent suctioning. On the second postoperative day, respiratory status stabilized, and the patient was discharged home.

Lipid resuscitation: development in basic research and application to clinical practice

It has been nearly 15 years since the effectiveness of intravenous lipid emulsion in resuscitation from bupivacaine-induced cardiac arrest was reported by Weinberg et al. [1]. Despite the outstanding novelty and originality of this finding, it was not until a 2006 case report of a patient resuscitated with lipid emulsion after bupivacaine-induced refractory dysrhythmia and cardiac arrest that its clinical effectiveness was acknowledged [2]. This event was followed by a large number of case reports that showed the effectiveness of lipid emulsion for treating the central nervous system as well as cardiac toxicity induced by various kinds of local anesthetics [3–8]. Treatment with intravenous lipid emulsion has been incorporated into practice advisories of the Association of Anesthesiologists of Great Britain and Ireland, the American Society of Regional Anesthesia and Pain Medicine [9], and endorsed by the American Heart Association Advanced Cardiac Life Support (ACLS) guidelines [10] (Table 1). In response to widespread interest, numerous studies have been undertaken using various animal models [8]. Notably, most of the animal experiments have been focused on examining the effect of lipid on local anesthetic-induced cardiac toxicity, not central nervous system toxicity, probably because of the primary concern of resuscitation and the entirely different animal models required for studying these two types of toxicity. Animals under mechanical ventilation with oxygen are needed to examine the effect of lipid emulsion on cardiac toxicity of local anesthetics while eliminating the influence of hypoxia induced by sedation and convulsions preceding circulatory collapse [11–14]. In contrast, awake, spontaneously breathing animals are needed to observe its effect on the central nervous system toxicity [15]. Randomized clinical trials are no longer ethically defensible for studying local anesthetic toxicity. Moreover, clinical data from healthy volunteers given nontoxic doses of bupivacaine would not precisely reflect the condition at the onset of the toxic effects [16].

Dexmedetomidine infusion for sedation in the intensive care setting in an infant with airway compromise due to congenital mediastinal neuroblastoma

the effect of glues on catheters?’ We do not think we have enough information to exclude damage to the walls of catheters by Mastisol or Dermabond (Ethicon Inc., Somerville, NJ, USA) despite the fact that a lot of anesthesiologists use glues to fix different kind of catheters. In conclusion, we agree with Dr Thompson and Aasheim, epidural catheters can inwardly migrate mainly in active infants. We think this complication is not rare, but it is little described probably because catheters are not checked daily. Inward migration of a catheter can promote more dangerous complications such as epidural infection and high epidural block. For this reason, we think meticulous control of dressing and length of catheter is mandatory during postoperative continuous epidural analgesia in children.

Introduction of ERAS(®) program into clinical practice: from preoperative management to postoperative evaluation : Opening remarks.

We, the chairpersons, chose ‘‘Enhanced Recovery After Surgery’’ as a topic of the 2013 Journal of Anesthesia symposium held on May 23, 2013. After reviewing all the manuscripts assigned to the section editor (Y.O.) from 2011 to 2012, we found that a large number of anesthesiologists are interested in preoperative evaluation and intraand postoperative management for improving patient satisfaction and prognosis. Besides providing adequate postoperative analgesia and preventing nausea and vomiting, developing a program targeting enhanced recovery after surgery has been one of the most popular themes among us. The initial idea of enhanced recovery goes back almost half a century, as oral rehydration therapy for the treatment of infectious disease [1]. Based on a long history and cumulated knowledge, the multimodal ERAS protocol has been established and is still under evolution [2]. In this symposium, we aimed at a comprehensive review of the concept of enhanced recovery after surgery, from preoperative management to postoperative evaluation, by four outstanding symposists. Dr. Taniguchi, a co-founder of enhanced recovery programs in our country, elaborated the introduction of the modified ERAS protocol in his institute [3]. He developed this program, originally named ‘‘preoperative oral rehydration therapy,’’ for improving the perioperative safety and satisfaction of the patients. His lecture, describing the modified ERAS protocol according to the current medical system in Japan and improved patient prognosis after its introduction, would have been quite informative to every Japanese anesthesiologist who is starting these programs in their institutes. Dr. Yatabe showed that preoperative oral carbohydrate treatment, in addition to contributing to shortening the preoperative fasting period, improves insulin resistance and prevents a decrease of body temperature during anesthesia in clinical and experimental studies [4]. Adequate control of both blood glucose and body temperature is a part of the ERAS protocol and significantly influences the postoperative outcome. Dr. Kitayama presented the effects of intraoperative analgesia with peripheral nerve block including transversus abdominis plane block and rectus sheath block with local anesthetics as well as thoracic epidural block with opioids. He also validated its safety from the point of plasma concentration of local anesthetics [5]. Dr. Shibata reviewed various kinds of peripheral nerve block, including brachial plexus block, from the point of nerve injury. Anesthesiologists are responsible for neurological complications induced by nerve block. He explained the differential diagnosis of nerve injury for early detection and prompt treatment [6]. Dr. Tanaka [7] developed the Japanese version of the quality of recovery (QoR) 40, a score for evaluating the quality of postoperative recovery originally created by Myles [8]. He translated the original score into Japanese, with modifications according to the Japanese medical system and validated from numerous aspects. The Japanese version of the QoR40 will appear in this manuscript. We believe this symposium was informative and has provided practical knowledge to many anesthesiologists. Y. Oda (&) Department of Anesthesiology, Osaka City General Hospital and Children’s Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan e-mail: odayou@msic.med.osaka-cu.ac.jp

Anesthesia in an adult patient with tracheal hemangiomas: one-lung ventilation for lung lobectomy

Primary tracheal tumors are rare in adults, and careful airway management is required during anesthesia for affected patients. We report the case of a patient with tracheal hemangiomas undergoing nontracheal operation. A 61-year-old woman was scheduled for a lung operation. During preoperative examination, hemangiomas were detected on the tracheal mucosa. As she was asymptomatic and the degree of airway stenosis was small, treatment was not required for the hemangiomas, and left upper lobectomy for lung cancer was scheduled. After induction of general anesthesia, a regular tracheal tube was inserted under fiberoptic bronchoscopy, with care taken to prevent damage to the hemangiomas. An endobronchial blocker was inserted for one-lung ventilation. The operation was performed uneventfully, and the tracheal tube was replaced postoperatively with a laryngeal mask airway while the patient was under deep anesthesia and neuromuscular blockade. The mask was removed after confirming lack of bleeding from the hemangiomas. No hypoxia or other complications occurred during or after the operation.

Anesthetic management of three pediatric cases with Pena-Shokeir syndrome.

Pena–Shokeir syndrome is a rare, early lethal disease. It is characterized by fetal growth restriction; craniofacial deformities, for example micrognathia and microcephaly; multiple ankyloses; and pulmonary hypoplasia. For patients with this syndrome, maintenance of airway and control of perioperative respiratory complications are important for anesthetic management. We report 3 pediatric cases of Pena–Shokeir syndrome undergoing tracheostomy and arthrolysis under general anesthesia using sevoflurane, nitrous oxide, fentanyl, and vecuronium bromide. Anesthetic procedures including mask ventilation, tracheal intubation, and extubation were successfully performed without complications during and after surgery. In patients with Pena–Shokeir syndrome, inhalational anesthetics can be safely used for induction and maintenance of anesthesia, although it is important to assume that difficult airway management might be encountered.

Rapid sequence spinal anesthesia for the most urgent cesarean section: a simulation and clinical application

Rapid sequence spinal anesthesia is a recently developed technique for the most urgent, category-1 cesarean section. To successfully perform this technique, it is important to multi-disciplinarily discuss with all staffs related to delivery, make a local protocol in each hospital and simulate the procedure with them. Owing to the above preparation, we were able to perform the technique smoothly also in the real patient. Considering possible benefits of rapid sequence spinal anesthesia, we should prepare enough before we use it in the actual clinical situations.

Intraoperative ventricular tachycardia during hepatectomy with right atrium and inferior vena tumor derived from hepatocellular carcinoma

To the Editor: Institutional Review Board approval and informed concent were exempted because no ethical problem was involved in this case report. After the operation, informed consent for publication was obtained from the patient. A 65-year-old man with hepatocellular carcinoma in the middle hepatic vein invading the right atrium and inferior vena cava presented for hepatectomy and resection of the right atrium tumor under cardiac pulmonary bypass. Preoperative electrocardiogram and coronary angiography were normal. Preoperative transthoracic echocardiography indicated the right atrium tumor extended from the middle hepatic vein via the inferior vena cava. Hepatectomy was started before resecting the right atrium tumor under cardiopulmonary bypass. The anesthetic method was general anesthesia maintained with sevoflurane, fentanyl, and rocuronium. Transesophageal echocardiographic examination (TEE) before surgery revealed a tumor in the right atrium and opening of the inferior vena cava (Fig. 1a). The size of the right atrium tumor was about 2 9 3 cm, and the inferior vena cava was largely occupied by the tumor. When hepatectomy had almost been completed, the lead II electrocardiogram suddenly showed an elevated ST wave that became a wide QRS wave. The patient developed an acute decrease of end-tidal carbon dioxide and a loss of arterial pressure with the waveform. TEE revealed a deformed right atrium tumor and occlusion of the tricuspid valve caused by the tumor (Fig. 1b). The occlusion of the tumor was not released. Direct cardiac massage was performed immediately, and adrenaline and xylocaine were given intravenously. About 3 min later, the ECG returned to a normal waveform and the patient recovered from cardiovascular collapse. After cardiopulmonary resuscitation, hepatectomy was continued and completed. Subsequently, resection of the right atrium tumor under cardiopulmonary bypass was performed with no problems. There are many reports of successful operations and management of surgery combining hepatectomy and resection of a right atrium tumor, but intraoperative cardiovascular collapse during surgery has not been reported. The finding of TEE during ventricular tachycardia revealed that the shape and size of the right atrium tumor changed and that the tricuspid valve was occluded by the tumor. This finding indicated that resecting the liver had loosened the right atrium tumor, and occlusion of the tricuspid valve caused by the loosened tumor precipitated cardiovascular collapse. Transesophageal echocardiographic examination is an effective monitoring method for detecting an intraoperative critical incident [1, 2]. Our report suggests that sudden cardiovascular collapse may occur as a result of occlusion of the tricuspid valve by a tumor during hepatectomy that is complicated by a right atrium and inferior vena tumor, and TEE is essential for monitoring hepatectomy complicated by such a metastasis. K. Kamiutsuri (&) R. Okutani Y. Oda Department of Anesthesiology, Osaka City General Hospital and Children’s Hospital, 2-13-22 Miyakojima-hondori, Miyakojimaku, Osaka, Osaka 534-0021, Japan e-mail: k-kamiutsuri@hospital.city.osaka.jp