We retrospectively compared the peri-operative respiratory functions of the complete thoracoscopic esophagectomy in the prone position (group P, n=15) and video-assisted thoracoscopic esophagectomy with mini-thoracotomy in the left lateral position (group L, n=10). Intra-operative arterial blood gas analysis indicated no significant difference in PaO2/FIO2 during one lung ventilation between the two groups (220.2 ± 82.8 vs 192.7 ± 111 Torr, p=0.513). The duration from the end of surgery to extubation in group P was significantly shorter than that in group L (P<0.01). In conclusion, thoracoscopic esophagectomy in the prone position contributed to maintenance of pulmonary oxygenation, and reduced the duration of mechanical ventilation in the post-operative period.
Tracheobronchial stenting is a procedure in which a stent is inserted into a stenotic site of the airway. Which ventilation is optimal for tracheal stenting is controversial. In this study, we retrospectively investigated patients who had undergone tracheal stenting, and evaluated the incidence of oxygen desaturation (SpO2 : <95%), mean intraoperative P/F ratio, pH, and PaCO2 in spontaneous respiration (SP) and controlled ventilation with muscle relaxants (MR) groups. Of patients who underwent tracheal stenting in our hospital between July and November 2013, we evaluated 10 patients each in the SP and MR groups. For anesthesia, TIVA with propofol TCI and remifentanil was performed. In the SP group, spontaneous respiration was maintained. In the MR group, a rigid endoscope was inserted after the administration of muscle relaxants and controlled ventilation performed. The incidences of oxygen desaturation in the SP and MR groups were 50 (n=5, 95%CI : 23 to 76%) and 0% (n=0, 95% CI : 0 to 28%), respectively. In the SP group, the mean intraoperative pH was lower than in the MR group (7.26±0.05 vs. 7.40±0.07, respectively, P<0.001). In this group, the mean PaCO2 was higher (63.5±12.3 vs. 40.6±8.58, respectively, P<0.001), and the mean P/F ratio was lower (206.5±47.1 vs. 387.2±68.1, respectively, P<0.001). Controlled ventilation with muscle relaxants during tracheal stenting reduced the incidence of oxygen desaturation, maintaining a favorable respiratory status. Note : P/F ratio＝PaO2/FIO2
We report a case of laparoscopic surgery performed on a patient with ventriculoperitoneal shunt (VPS), without removing or otherwise manipulations the shunt tube. Rising intra-abdominal pressure poses a risk of tube damage, retrograde infection, and intracranial pressure (ICP) increase. We therefore tried to minimize the tilt of head-down position and intra-abdominal pressure during surgery, and placed the end of the VPS tube out of the surgical operating field. Additionally, we measured the diameter of the optic nerve sheath as an indirect indicator of ICP, which showed that the ICP did not increase significantly during surgery. By using these techniques, it was possible to carry out the surgery safely.
Only a few reports describe intraoperative priapism following regional anesthesia. Priapism can occur during transurethral resection of bladder tumors (TUR-Bt), normally in response to difficulty in inserting an urethrocystoscope into the urethra. If this occurs, the planned surgery may be canceled. Therefore, anesthesiologists need to respond rapidly to address this situation. Here we report a case of priapism treated with atropine in a patient undergoing TUR-Bt under spinal anesthesia. A man in his 60s with bladder cancer was scheduled for TUR-Bt. Spinal anesthesia was performed with 0.5% isobaric bupivacaine at the L3-4 space. Immediately after the commencement of the operation, the urologist had difficulty in inserting the urethrocystoscope into the urethra because of priapism. The priapism was resolved by atropine, and the operation was resumed. Intraoperative priapism appears to be a reflex mediated by local stimulation of the penis. Although the specific mechanisms responsible for priapism remain unclear, our case suggests that atropine can resolve priapism by inhibiting the sacral spinal cord parasympathetic pathway.
We report a case of a 36-year-old primipara with interstitial pneumonia and mild pulmonary hypertension. Because of a decrease in oxygen saturation (SpO2) level, she was administered domiciliary oxygen therapy at 21 weeks of pregnancy. Cesarean delivery under combined spinal-epidural anesthesia (CSEA) was planned at 32 weeks and 6 days of pregnancy. An epidural catheter was inserted at L2/3, and hyperbaric bupivacaine (0.6 mL) and fentanyl (10 μg) were injected into the spinal subarachnoid space from L3/4. During the surgery, a local anesthetic drug was also administered through the epidural catheter whenever necessary (sequential CSEA). The level of anesthesia was below the level of Th6 both before and after the surgery. High spinal anesthesia may lead not only to hypoxemia but may increase the severity of pulmonary hypertension as well. Through the use of sequential CSEA, this case could be managed and stable hemodynamics achieved while avoiding unexpected rise in the level of anesthesia.
While performing craniotomy surgery under perioperative mechanical ventilation, care should be taken to avoid hypercapnia in the perioperative period. Herein, we report a brain stem tumor removal surgery performed successfully under PaCO2 management by using adaptive support ventilation (ASV) with INTELLiVENT®-ASV (iASV). A 34-year-old man was diagnosed with a brain stem tumor and underwent craniotomy for tumor removal. Continuous mechanical ventilation was provided on the day of the surgery. After admission to the intensive care unit, an appropriate iASV mode was selected to avoid hypercapnia. Over the course of 12 h, EtCO2 and PaCO2 were both generally stable at 36-38 mmHg. iASV mode defines the appropriate %MV depending on the height and sex of the patient and automatically changes the respiratory settings by continuously monitoring EtCO2 and PaCO2. This function may allow smooth and accurate adjustment of ventilation during recovery from neurosurgical procedures.
A 78-year-old male patient receiving chemotherapy for esophageal cancer suddenly lost consciousness and subsequent intensive care was initiated after resuscitation on hospital day 12. Laboratory examination showed an extreme hyperosmotic state (serum sodium concentration : 169 mEq/L, blood sugar level : 817 mg/dL). Serum osomolarity was corrected within 1 week ; however, the patient was still in coma and mechanical ventilation was required. CT demonstrated cerebral infarctions in the posterior lobes and electroencephalogram showed cortical activities. Two months later, the conscious level suddenly improved and spontaneous respiration was observed. MRI findings strongly suggested the development of central pontine myelinolysis. The patient underwent rehabilitation training and was finally moved to a neighboring hospital without mechanical ventilation on hospital day 126.
We plan to initiate a clinical trial in Japan, to investigate the safety, of transplanting human iPSC-derived dopaminergic progenitors (DAPs) in Parkinson’s disease patients, based on neurological scores and neuro-radiological examinations, such as MRI and PET. In this clinical trial, clinical grade “Stock iPSCs” will be used, established in the cell-processing center in CiRA (Center for iPS Cell Research and Application) will be used. DAPs are differentiated from stock iPSCs by adding small molecules and cytokines, and collected by cell sorter, and then transplanted by stereotactic surgery. We have confirmed the safety and efficacy of iPSC-derived DAPs in non-clinical studies. In this article, we discuss the details and future prospects of cell therapy for Parkinson’s disease.
Nearly 20 years have passed since propofol was introduced in Japan. Herein, the author provides some basic information regarding propofol anesthesia. It is essential to know the pharmacokinetics and pharmacodynamics of propofol as well as the differences between effect-site and plasma concentrations. Anesthesiologists have to consider both pharmacokinetic and pharmacodynamic differences such as changes caused by age and massive obesity. On the other hand, the concentrations displayed on the TCI pump are estimated or predicted concentrations, so the absolute values displayed are not important. EEG-derived monitors such as the BIS monitor are considered as complementary to the estimation of the hypnotic status caused by propofol instead of effect-site concentrations.