We report the case of a 6-year-old boy with large brain tumor, who had undergone fenestrated total cavopulmonary connection for hypoplastic left heart syndrome, and was scheduled to undergo craniotomy. Despite a long operation and massive bleeding, stable hemodynamic condition was obtained by infusion/transfusion therapy keeping high central venous pressure and preventing an increase in pulmonary vascular resistance. This case suggests that a deeper understanding of the interrelationship between Fontan physiology and cerebral circulation is necessary in patients with Fontan circulation during the neurosurgical procedure.
We report an unexpected poor prognostic lung cancer treatment case in which acute exacerbation of fibrotic interstitial pneumonia（FIP） occurred in a patient four days after lung surgery. Cases of acute exacerbation of FIP after lung cancer surgery causing death have been reported. In usual cases, FIP gradually worsens after surgery for several years before death. In our case, a 78-year-old male was diagnosed with lung cancer and underwent segmental resection by surgery in the right lower lung. Preoperatively he was not diagnosed with complicated FIP, but acute exacerbation of FIP occurred postoperatively and the patient deteriorated and eventually died.
From this experience, we will pay closer attention to preoperative FIP test and laboratory data, and will improve communication of these data to the surgeons. As invasive surgery has been linked to the acute exacerbation of FIP, we also recommend exploring non-invasive treatment to reduce this risk and protective lung management during anesthesia.
A 72-year-old man（166 cm, 80 kg, BMI 29 kg/m2）underwent removal of a left acoustic neurinoma in park-bench position. He was under a treatment for diabetes and hyperlipidemia. Four hours after taking the position, tea-colored urine appeared. His vital signs were stable without high fever, muscle rigidity, or electrolyte abnormalities, so surgery was continued. Redness in the skin of the lateral chest was noted after surgery. Rhabdomyolysis was diagnosed by the elevation of creatine phosphokinase（7,563 IU/L）, myoglobinuria（87 ng/mL）, and diffuse swelling of the right transverse abdominal and lumbar muscles on the day after surgery. Kidney dysfunction was not observed during the perioperative period. In this case, the main cause of rhabdomyolysis is long-term surgery in park-bench position. However, there are several other risks involved such as dehydration by fluid restriction and mannitol use and obesity. Attention should be paid to hypotension, dehydration, and electrolyte imbalances in addition to the particular position. Early detection and management of rhabdomyolysis is crucial.
Partial trisomy 16, a rare chromosomal abnormality, is associated with various manifestations, such as growth and developmental retardation, central nervous system malformations, and craniofacial dysmorphism. To our knowledge, there have been no reported cases of anesthetic management in a patient with partial trisomy 16.
A 98-day-old girl（height, 51 cm；weight, 4.0 kg）with partial trisomy 16 underwent laryngofiberscopic examination and magnetic resonance imaging under monitored anesthesia care. Sedation was initiated with a bolus dose of midazolam（0.5 mg）. Dexmedetomidine was subsequently administered as a bolus of 0.8 μg/kg over 20 min followed by 0.8 μg/kg/h infusion. Ketamine（5 mg）was immediately added before inserting the laryngofiberscope. The examination was performed with spontaneous breathing via the natural airway. No episodes of adverse respiratory events or hemodynamic instability occurred. Dexmedetomidine is useful for sedation in patients with partial trisomy 16.
Post-dural puncture headache（PDPH）is a complication of epidural anesthesia. We report a patient who developed headache after epidural catheter removal, which was initially treated as PDPH, but was followed by decreased level of consciousness. Blood tests revealed severe hyponatremia.
A 61-year-old man underwent thoracoscopic right lower lung lobectomy under general anesthesia with epidural anesthesia. On 2 POD, after epidural catheter removal, he complained of headache. We started conservative therapy as for PDPH with bed rest, fluid therapy and NSAIDs, but his symptom did not improve and he subsequently developed decreased level of consciousness on 10 POD. There were no significant signs in CT scan but serum sodium decreased to 113 mmol/L. Intravenous infusion of 3% hypertonic saline was started. Two days after treatment, his symptom was relieved with serum sodium at 125 mmol/L. Water restriction was continued until full recovery on 16 POD. Laboratory data suggested SIADH and hypoadrenalism. The patient started taking steroids and was discharged home without any complications on 26 POD.
PDPH is relatively common, but the lack of response to treatment should raise suspicion of differential diagnosis. Hyponatremia may induce headache, so it should be considered in the differential diagnosis of PDPH.
We present the anesthetic management of a 37-year-old woman（146 kg, 180 cm abdominal girth）with a giant ovarian tumor. She had a left ovariectomy at the age of 15 because of pedicle torsion in ovarian tumor. At the time of hospitalization, hematological data showed anemia and chest radiography showed elevated diaphragm. Her degree of peripheral arterial oxygen saturation was 93％. She could not fit in magnetic resonance imaging device because her abdominal girth was too big. We paid attention to hypoxemia during induction of anesthesia and re-expansion pulmonary edema during the operation. Arterial blood pressure, heart rate, CVP, cardiac output and stroke volume variation were monitored as circulatory parameters. Anesthetic management of patients with huge abdominal tumor is discussed.
A 62-year female patient who was a marathon runner was scheduled to undergo partial lung resection. Her preoperative electrocardiogram indicated a HR of 58 bpm, sinus rhythm, with high voltage. Anesthesia was performed with propofol, remifentanil, rocuronium, and thoracic epidural anesthesia. Fifteen min after the patient was shifted to the recovery room, her HR decreased to 26 bpm, and cardiac arrest occurred 1 min later. Resuscitation was performed with external cardiac massage and artificial ventilation via a bag valve mask. One mg epinephrine was administered intravenously, which resulted in reappearance of the pulse waveform on the ECG monitor and return to consciousness 3 minutes after the cardiac arrest. Transthoracic echocardiography did not indicate any abnormal findings in the recovery room. Postoperative interviews revealed that the patient had previously had recurrent sudden attacks of unconsciousness, which were probably due to severe self-correcting bradycardia. When a patient with an athlete’s heart undergoes anesthesia, it is necessary to understand the severity and frequency of any arrhythmia, including bradycardia.
“Guidelines for medical treatment and its safety in the elderly 2015” described a revised list of potentially inappropriate medications, going through several processes of clinical questions, and a systematic review. This paper, referring to the guidelines, describes treatments for mental symptoms such as insomnia, depression, and behavioral and psychological symptoms of dementia（BPSD）in the elderly.
It is important to keep in mind that non-pharmacotherapy should be performed before pharmacotherapy for symptoms in the elderly. It is also important to search for the causes of the symptoms and to manage them.
For pharmacotherapy of insomnia in the elderly, benzodiazepine drugs should be prescribed with special caution. Non-benzodiazepine drugs should also be used with caution due to similar risks of fall and fracture. For elderly patients with depression, tricyclic antidepressants should be prescribed with special caution due to severe anticholinergic effects. It is necessary to bear in mind that SSRIs pose a risk of gastrointestinal bleeding. Sulpiride should be prescribed with special caution due to the adverse effect of Parkinsonism. It is reasonable to monitor the effects of cholinesterase inhibitors and memantine on BPSD in patients with Alzheimer’s disease. Typical anti-psychotics be avoided, and atypical antipsychotics should be used at an effective minimum dosage and duration.
In order to achieve efficient learning of ultrasound-guided nerve blockade（USGNB）, we should make maximum use of various sources. Textbooks provide knowledge about indications and anatomical information relevant to each USGNB procedure. Learners should integrate the knowledge of gross anatomy with that of sonoanatomy to confidently visualize ultrasound images. One of the best sources for web-based learning in regional anesthesia is NYSORA.com. High-resolution movies and pictures help learners understand the procedure intuitively. Numerous educational movies are also shared on YouTube. During hands-on scanning of healthy volunteers, learners can experience ultrasound probe manipulation techniques such as sliding, rotation, tilting and rocking. The Blue PhantomTM is useful in the early stages of learning needle insertion, but it provides high needle visibility, which can mislead learners into false confidence regarding their clinical ability. Meat phantoms are inexpensive and provide a more realistic simulation of needle guidance in actual clinical practice. With a meat phantom, learners can practice all three techniques of a USGNB procedure, that is, ultrasound probe manipulation, needle insertion and local anesthetic injection. After acquiring this knowledge and mastering these techniques, learners can advance to clinical training under the supervision of experienced anesthesiologists.
Growth in the elderly population has increased the number of geriatric patients undergoing surgical operations under anesthesia. Consequently, postoperative delirium（POD）and postoperative cognitive dysfunction（POCD） have become a common problem in elderly patients. Both POD and POCD have been shown to be associated with long-term disability and higher health care costs. Currently, however, there are few recognized intervention strategies for preventing POD/POCD. Although its pathogenesis involves various factors, accumulating evidence suggests that neuroinflammation plays a key role in the development of POD/POCD. Therefore, surgery-induced neuroinflammation processes including the microglial activation pathways will be promising therapeutic targets. Specifically, our recent findings from preclinical research using aged animals show the benefits of adequate postoperative analgesia for the prevention of POD/POCD. In this review, we discuss the current overview and preclinical highlights regarding the contribution of pain in the development of POD/POCD.
Postoperative pain is induced by tissue injury and influenced by anesthesia and the patient’s background. Although inappropriate analgesia is linked to the incidence of chronic post-surgical pain, analgesics including NSAIDs, opioids, and local anesthetics have immune-suppressive effects, implying that the use of these analgesics may inhibit acute inflammation and the wound healing process, resulting in the occurrence of surgical site infection and delayed wound repair. The correlation between the development of postoperative pain and surgical site infection, and the impact of postoperative analgesia on the outcome, have been indicated in recent years.
Pain is a complex issue, and Quality Recovery 40（QoR-40）, a quality measure of multidimensional scale recovery, has been used to assess postoperative pain in recent years. There is also a Japanese version, which is characterized by being able to conveniently measure the outcome seen from the patient side of the perioperative period（comfort, pain, feeling, physical function, patient support and emotion）like QoL scale. QoR-40 is used worldwide to measure the quality of recovery after anesthesia surgery. There is evidence of its reliability and relevance, and it could be used more frequently in evaluating postoperative pain in the future.
Patients with chronic pain demonstrate impaired endogenous analgesia. In animal studies, depletion of noradrenergic neurons by neurotoxins diminished analgesia induced by noxious stimulation, with slower recovery from neuropathic pain. Our previous studies reported that rats with prolonged neuropathic pain demonstrate impaired noradrenergic descending pain inhibition when compared with pain-naïve subjects. The analgesic efficacy of gabapentin was also reduced following nerve injury. These findings suggest that improving or enhancing endogenous analgesia may be a novel therapeutic strategy for chronic pain patients. Recent studies suggest that endogenous analgesia also plays important roles in acute postoperative pain. Depletion of noradrenergic neurons induces slower recovery from incisional pain. Recently we reported that repeated administration of amitriptyline attenuated impaired noradrenergic descending inhibition. In this study, we discuss a novel preventive strategy for addressing acute and persistent postoperative pain.
In segmental anesthesia and neural block, the washout of anticoagulants and antiplatelet agents in antithrombotic treatment should be safe, balancing the risks of thrombus during washout and hemorrhage during procedures. To solve this problem, the Japanese Society of Anesthesia, the Japan Society of Pain Clinicians, and the Japan Society of Regional Anesthesia established washout guidelines for antithrombotic treatment. These first guidelines in Japan put more emphasis on hemorrhage prevention than thrombus. However, this landmark is based on weak evidence due to the very low frequency of complications such as hemorrhage and hematoma, suggesting it should be continuously and appropriately revised.
Spinal hematoma after neuraxial anesthesia is an uncommon but devastating complication. Since perioperative use of anticoagulants and antiplatelet drugs has recently increased, there is a growing concern regarding the safety of neuraxial anesthesia in patients receiving antithrombotic treatment. To improve patient safety, a guideline for performing regional anesthesia in those patients was recently published in Japan. The actual incidence of hematoma associated with neuraxial anesthesia is difficult to measure. In addition, since no prospective randomized study has been conducted to assess the relative risk of spinal hematoma associated with anticoagulants and antiplatelet drugs after neuraxial anesthesia, the guideline is based on previous reviews, case series, case reports, and guidelines published abroad.
The Japanese guideline describes peripheral nerve blocks in surgical patients receiving antithrombotic drugs. There is little evidence regarding the risk of hemorrhagic complications after peripheral nerve block in anticoagulated patients. The risk classification depends on technical factors such as depth of nerve and patient factors such as bleeding diathesis. Patients who receive deep peripheral nerve block are at higher risk of hemorrhagic complications. Antithrombotic drugs should be discontinued before the block procedure based on their pharmacological properties and the risk classification.