It has been reported that pregnant women who have undergone surgery to correct congenital heart disease have little cardiac reserve; thus, it is necessary to consider adjustments to the method of delivery for the purpose of minimizing the load on the heart. Epidural labor analgesia was administered to a primiparous woman who had previously undergone surgery for congenital heart disease. Forceps delivery was performed to shorten the second stage of labor, and patient-controlled epidural analgesia was also used. Heart failure and arrhythmia had not occurred during the pregnancy. No considerable changes in blood pressure progression of labor, and the statuse of the fetus was good throughout labor. In such cases, epidural labor analgesia may promote stable hemodynamics in pregnant women who are considered to be at risk during delivery, and thus, avoiding the need for a hysterotomy.
We report the case of surgery using the prone position for a patient whose sternum had been removed following poststernotomy mediastinitis. The 83-year-old male patient had been scheduled for C4-6 laminoplasty and C3 and C7 dome plasty for cervical spinal canal stenosis. He had a surgical history of debridement, with removal of the infected sternum and reconstruction using the omentum because of poststernotomy mediastinitis following a median sternotomy two years earlier. We were uncertain about the stabilization of the thorax and the pressure on the heart if a patient with no sternum was placed in the prone position. After this case, we conclude that spinal surgery can be safely performed using the prone position for a patient who has undergone removal of the sternum and re-closure with the omentum.
We herein report the case of a patient with an Aorto-esophageal fistula (AEF) with hypovolemic shock who survived with the use of a nasal SB tube and thoracic endovascular aortic repair (TEVER). A nasal SB tube is commonly used to treat esophageal varices. In the present case, we referred to the nasal endoscopic observations and blindly inserted the nasal SB tube. An AEF is a rate and usually fatal condition, but the number of reports has recently been increasing, because it is an occasional preoperative complication of TEVER. The use of a nasal SB tube is beneficial for treating an AEF. However, depending on the situation, an esophagus or aortic aneurysm may be ruptured by blindly inserting a nasal SB tube. Therefore, that the use of a SB tube should be made carefully, and it should be inserted referring to endoscopic observations if possible.
In this study, we compared the results of bedside point-of-care testing and conventional laboratory measurements of human B-type natriuretic peptide N-terminal fragment in 45 samples from 17 critical care patients admitted to the intensive care unit in our hospital during a 2-month study period; of these, 64% of the samples were from post-pediatric cardiac surgery patients. The accuracy and precision of the two methods were analyzed using Bland-Altman plots. In contrast to the multiple regression analysis, which showed an adjusted regression coefficient R2 of 0.990, the plot showed a bias of 13.7% and an upper coefficient limit of 27.4%. In the subgroup analysis of measurements less than 1200 pg/mL, the age of the patients was a significant factor in the regression analysis, although the plot showed a similar tendency of error. These results suggest that point-of-care B-type natriuretic peptide N-terminal fragment measurement is a promising tool in critical care evaluation of heart failure patients, as long as the regression model for the bias is used, and that differences greater than 27.4% need to be considered significant.
Although two-dimensional speckle strain enables earlier detection of myocardial ischemia with higher sensitivity and specificity compared with other modalities, it has not yet been widely used in surgical settings. We report a case of severe mitral regurgitation that developed after a skin incision in a patient undergoing coronary artery bypass grafting. Longitudinal strain analysis in this patient demonstrated that an increase in regurgitation grade was associated not only with increased afterload but also with tethering owing to regional myocardial ischemia. We suggest that strain analysis is useful for monitoring patients with ischemic mitral regurgitation.
A 32-year-old pregnant woman was diagnosed with ventricular tachycardia at 9 weeks gestation. She was administered a β-blocker, but the frequency of ventricular tachycardia increased in late pregnancy. She experienced labor pains at 37 weeks gestation, whereupon she underwent cesarean section. In the operating room, a defibrillator pad was placed on her chest for external defibrillation, and an epidural catheter was inserted at the T12~L1. Spinal anesthesia was performed with 1.8 ml of 0.5% hyperbaric bupivacaine and 10 μg of fentanyl at L3~4, and analgesia was achieved from T3 to S5. We administered ephedrine intravenously for hypotension from spinal anesthesia. Ventricular tachycardia did not occur during the surgery, and the operation completed without any complication in the mother or the child. We conclude that combined spinal-epidural anesthesia is effective and safe for cesarean section in patients with ventricular tachycardia.
Patients with Loeys-Dietz syndrome are known to have cardiovascular anomalies, such as aortic root dilatation and aortic valve insufficiency, as well as thoracic deformities, including funnel chest. Therefore, to treat such patients, surgical corrections of thoracic deformities may be indicated in addition to cardiac surgeries. We encountered a patient with Loeys-Dietz syndrome who underwent anesthesia for surgical correction of funnel chest, in combination with valve-sparing aortic root replacement.
A 72 year-old man was scheduled for aortic valve replacement surgery for aortic stenosis and regurgitation complicated by infective endocarditis. The operation lasted longer than scheduled and was not uneventful due to second pump run to repair perivalvular leakages. Shortly after weaning the patient off of cardiopulmonary bypass, the staff members observed the fire in the OR. Within seconds, the fire burned down the pulmonary artery catheter, surgical drapes and the breathing circuits. We immediately stopped all the fresh air supply lines and the team succeeded in extinguishing the fire using bottled saline. After examining the patient's trachea using the fiber optic scope, we connected the patient to the new breathing circuit and restarted mechanical ventilation. After making sure that the patient was not harmed in any way, chest closure was started. The postoperative course was uneventful. The subsequent investigation by the fire department revealed that the cause of the fire was a malfunctioning of the electrocautery devise. The incidence of operating room fire is not negligible, and therefore, it requires constant vigilance and periodic training on the part of caregivers working in the OR. According to the Practice Advisory for the Prevention and Management of Operating Room Fires published by the American Society of Anesthesiologists, appropriate physical condition of caregivers, installation of the carbon dioxide fire extinguisher in the OR, and knowledge of operating room fire procedures shared by all the staff members are of the essence to prevent and manage operating room fires.
We measured thromboelastometry (ROTEMTM, A10: value of 10 minutes), fibrinogen concentration, and platelet counts during cardiopulmonary bypass. We estimated the necessity for blood transfusions from the end of cardiopulmonary bypass to 24 hours post-surgery in 51 patients undergoing adult cardiac surgery. The values that indicated the necessity for fresh frozen plasma were FIBTEM (A10) <6 mm and fibrinogen concentration<145 mg/dl. The values that indicated the necessity for platelet concentrates were platelet counts <80,000/μl and [EXTEM (A10)-FIBTEM (A10)] <30 mm. The results of this study indicate that, 1) FIBTEM (A10) estimates the necessity for fresh frozen plasma as well as fibrinogen concentration, 2) [EXTEM (A10)-FIBTEM (A10)] and platelet counts estimates the necessity for platelet concentrate, and 3) normalization of fibrinogen concentration >200 mg/dl or FIBTEM (A10) >10 mm and normalization of platelet counts >80,000/μl or [EXTEM (A10)-FIBTEM (A10)] >30 mm decreases the amount of post-operative bleeding by 30~50%.