Lactated Ringer’s solution and acetated Ringer’s solution are used for extracellular fluid replacement during neurosurgery. Since these solutions are glucose- and Mg-free, they may precipitate potentially serious complications partly due to hypomagnesemia. We compared newly-available Mg- and 1% glucose-containing acetated Ringer’s solution with conventional Ringer’s solution by measuring ionized Mg concentration, glucose metabolism, rate of occurrence of arrhythmia and hypertension, and neurological outcome during neurosurgery. Sixty patients scheduled for neurosurgery were randomly assigned into three equal groups; those who received acetated Ringer’s solution containing 1% glucose and Mg (Group 1), lactated Ringer’s solution(Group 2), and acetated Ringer’s solution(Group 3). The ionized Mg blood concentration was maintained in Group 1 while gradual falls were observed in both Group 2 and Group 3. Although a slight rise in blood glucose was observed in the Group 1, no profound hyperglycemia was noted. The incidence of arrhythmia and hypertension, and the neurological outcome, were not different among the groups. We conclude that acetated Ringer’s solution containing Mg and 1% glucose seems effective in maintaining blood Mg concentration without causing profound hyperglycemia, hypertension, or lethal arrhythmia during neurosurgery.
We have reported a very rare case of biatrial ball thrombosis. A 71-year-old man was admitted with cardiac failure and tachycardia of atrial fibrillation. He had a long history of atrial fibrillation without anticoagulation therapy. Cardiac failure and tachycardia were improved with medical therapy. Echocardiography showed biatrial giant tumors. Removal of the tumors was carried out with the aid of cardiopulmonary bypass. Pathological examination revealed that the right and left atrial tumors were both organized thromboses. His postoperative course was uneventful, and he was discharged on the 17th postoperative day. Only atrial fibrillation is considered to have had an important role in the etiology of biatrial thrombosis. Therefore we suggest that he should be kept on anticoagulation to avoid recurrence of intra-cardiac thrombosis.
Primary right atrial myxoma is very rare. We report the anesthetic management of an emergent surgical resection of a right atrial myxoma in a 48-year-old female patient. Preoperative echocardiography revealed a right atrial mass of 80×34mm. Arterial blood gas showed marked hypoxemia with an oxygen tension(PaO2) of 52.5mmHg and oxygen saturation of 85.6%. Anesthesia was induced and maintained with propofol, remifentanil and vecuronium. We inserted a Swan-Ganz catheter from the internal jugular vein to monitor pulmonary arterial pressure. The tumor was removed under cardiopulmonary bypass and a patent foramen ovale(PFO), which had not been detected in preoperative transthoracic echocardiography, was found and closed. Arterial blood gas showed normal oxygenation with PaO2 of 569mmHg on FiO2 1.0 after weaning from cardiopulmonary bypass. The intraoperative hemodynamic conditions were stable without cardiopulmonary complications. Right atrial myxoma can produce functional stenosis of the tricuspid valve and cause an increase of right atrial pressure. Thus, right to left shunting can occur through PFO and result in central cyanosis in such patients. Attention must be given to hemodynamic stability and the possibility of tumor obstruction and dissemination in anesthetic management of right atrial myxoma.
Many kinds of anesthetic regimens are employed for fast-track cardiovascular surgery. We introduce our fast-track anesthesia method using remifentanil aimed for tracheal extubation in the operation room after cardiovascular surgery. Anesthesia was induced and maintained by target controlled infusion of propofol(in cases using cardiopulmonary bypass(CPB)) or sevoflurane(in cases not using CPB) with remifentanil infusion 0.3mcg/kg/min. Intravenous fentanyl infusion 0.5μg/kg/hr was started at about 2 hours before the end of surgery for postoperative analgesia. After the surgery, patients were awaken and extubated if chest X-ray didn’t show any abnormal signs. Tracheal extubation in the operation room was achieved 58.3% of patients, and no severe complication was observed. Compared with having been possible for the operating room extubation as for 76.5% of cardiac surgery, the vascular surgery was able to do the operating room extubation only 14.3%(p=0.005). However, when the cases which were able to carry out the extubation was included within 4 hours after ICU entering, the extubation was possible for 83.3% of total cases. Thus, this anesthetic method with remifentanil could be used as one of regimens for fast-track cardiovascular anesthesia.