Two cases of non-MICS surgery successfully managed with Port-Access EndoCPB system

We report two cases of non-MICS surgery successfully managed with Port-Access EndoCPB system. The first patient is a case of non-ruptured giant aneurysm of middle cerebral artery proposed for clipping procedure under hypothermic cardiopulmonary arrest. The second patient is a case of infectious pseudoaneurysm of the ascending aorta. We conclude that this system can be a powerful option of anesthetic strategy for the patients in need of cardiac arrest without having severe physical stress like sternotomy.     

Anesthetic management of children with neuroblastoma

Study Objective: To review the 11-year anesthetic experience with neuroblastoma at Children's Hospital Medical Center, Boston, MA.

Design: Retrospective study.

Setting: Children's Hospital, Boston, MA.

Patients: 59 consecutive children with neuroblastomas who underwent surgical procedures between 1977 and 1989.

Interventions: Symptoms, physical findings, laboratory data, and results of echocardiographic examination were recorded. Type of chemotherapy and urine catecholamine levels were noted. Intraoperative information was extracted about the surgical procedure, anesthetic technique, blood loss, and intraoperative vital sign changes. Postoperative data were reviewed for complications.

Measurements and Main Results: 18 patients presented with a posterior mediastinal tumor. Five children presented with stridor, wheezing, pneumonia, and pleural effusion. Two children presented with hypertension. Left ventricular ejection fraction was within normal limits preoperatively in all patients evaluated by echocardiography. intraoperative hypertension and tachycardia occurred in 3.5% of the children during tumor manipulation. No hypotension was noted following tumor removal. Of the 18 patients presenting with a posterior mediastinal mass, 3 had tracheal deviation caused by the tumor. The intraoperative course and extubation were uneventful in 2 of the patients, and the other patient remained intubated postoperatively. No adverse effect was identified for any particular anesthetic drug or technique used.

Conclusions: Although neuroblastomas may be associated with hypertension upon presentation, intraoperative hypertension is rare. Tracheal compression and deviation were noted in 5.2% of patients with posterior mediastinal masses; however, airway complications did not occur. No specific optimal anesthetic regimen can be recommended.     

Anesthetic management of patients with cardiomyopathies

Anesthetic management of patients with cardiomyopathy was studied. In the past 8 years, we experienced 24 surgical procedures for 16 patients complicated with cardiomyopathy of whom 6 cases with hypertrophic type (HCM) and 10 cases with dilated type (DCM). In HCM there was no correlation between the incidence of intraoperative complication and preoperative evaluation by New York Heart Association. In HCM cases who revealed atrial fibrillation, conduction disturbance on ECG and hypokinesis on echocardiogram resulted in high incidence of cardiac complication during anesthesia. Induction of anesthesia is extremely risky if the anesthesiologist is not aware of the presence of cardiomyopathies. In DCM, preoperative episode of heart failure, arrhythmias and conduction disturbance on ECG were considered as anesthetic risk factors. Both in HCM and DCM, there were no statistical significance in complication between general anesthesia and epidural anesthesia. The authors recommend epidural technique as a method of choice for HCM patient.     

Anesthetic management of patients with tracheal T-tubes

Aims:  To better inform the preoperative anesthesia assessment, we review the rationale of tracheal T-tubes and the maintenance they require. We then describe specific intraoperative techniques to administer inhalational agents and maintain respiration in patients with tracheal T-tubes.
Background:  Tracheal T-tubes maintain airway patency in the healing phases of laryngotracheal reconstruction or in the setting of extrinsic or intrinsic airway collapse. The T-tube comprises a superior limb, an inferior limb, and an anterior limb projecting from a tracheotomy site. Negotiating tracheal T-tubes may present significant anesthetic challenges in both elective and emergent circumstances.
Methods:  The intraoperative ventilation techniques in patients with tracheal T-tubes are reviewed as well as pre and postoperative T-tube maintenance strategies.
Results:  Twelve techniques to connect anesthetic circuitry to tracheal T-tubes in different perioperative clinical scenarios are detailed.
Conclusions:  T-tubes are a well-established method for supporting the airway in both adults and children. However, the very design of the T-tube poses unique anesthetic management issues before, during, and after the operation. Anesthetic administration and gas exchange may be effectively achieved through a variety of methods, which we describe in detail.     

Anesthetic management of a patient with narcolepsy

We report the anesthetic management of a narcoleptic patient performed using sevoflurane–remifentanil with bispectral index (BIS) monitoring. A 22-year-old man, who was diagnosed with narcolepsy at the age of 17, requested endoscopic sinus surgery, under general anesthesia, for chronic allergic rhinitis. On the morning of the day of operation, he took his daily dose of modafinil, used to control narcolepsy. Anesthesia was induced by 5% sevoflurane and maintained with sevoflurane and continuous infusion of remifentanil and 60% oxygen in conjunction with BIS monitoring. BIS values were between 47 and 58. Duration of surgery was 150 min. After surgery, the patient emerged from anesthesia within 10 min and was extubated. His recovery was uneventful. We found the use of BIS monitoring for titrating sevoflurane concentration in a narcoleptic patient is useful for preventing not only oversedation but also intraoperative awareness caused by the preoperative medication.     

Anesthetic management of patients with tracheal bronchus

The incidence of a tracheal bronchus supplying the right upper lobe has been reported to be in the range of 0.1 to 3%. We encountered 3 cases with the anomaly among 200 cases of lung surgery conducted over a year at our hospital. In the first case, we had difficulty in intubating the patient with a double-lumen tube. In the other two cases, the tracheal bronchus was detected by fiberoptic bronchoscopy during the lung surgery. Patients with a tracheal bronchus may be difficult or impossible to ventilate, especially when requiring unilateral lung ventilation. Therefore, the airway must be assessed carefully by fiberoptic bronchoscopy prior to unilateral lung surgery, keeping in mind the possibility of a tracheal bronchus, in order to design a safe way to secure it safely during the surgery.     

Anesthetic management of a boy with sialidosis

Sialidosis is an autosomal recessive disease caused by neuraminidase deficiency, which causes material rich in sialic acid to accumulate in various tissues and organs, leading to morphological and functional changes. Mainly the osteoarticular, cardiorespiratory, and central nervous systems are affected. We report the case of a 14-year-old boy diagnosed with sialidosis type 2 who was proposed for spinal column arthrodesis to treat severe thoracolumbar scoliosis. Physical examination revealed pectus carinatum; facial deformity and macroglossia; hypertelorism and frontal bossing; short neck; atlantoaxial subluxation; severe arthrogryposis of elbows, knees and wrists, coxa valga, and club foot. Relevant medical history included moderately severe aortic valve insufficiency and myoclonic epilepsy. Surgery was performed under balanced anesthesia. Awakening was delayed and the patient was transferred to the intensive care unit under mechanical ventilation. Anesthetic problems that can present in patients with such deformities include difficult airway, complicated management of associated cardiopathy, and difficult weaning from mechanical ventilation.     

Anesthetic management of parturients with Marfan syndrome

Ten pregnancies and 7 deliveries in 5 patients of Marfan syndrome were managed at our institution. Three patients were delivered with a cesarean section under general anesthesia, and one was delivered under epidural anesthesia. Three underwent vaginal delivery with epidural anesthesia. Two patients selected induced abortion, and one had a spontaneous abortion. Six of 7 neonates and all 5 mothers survived without any sequela. One had intrauterine fetal death due to dissection of aortic aneurysm. Simultaneous cesarean section and cardiovascular operation under cardiopulmonary bypass were performed in one case. In the parturient without progress of cardiovascular complication during pregnancy, painless labor under epidural anesthesia is our first choice to minimize hemodynamic derangement. Invasive arterial blood pressure and central venous pressure were monitored in all cases of vaginal delivery for tight hemodynamic control. Epidural anesthesia is also preferred in cases of elective cesarean section for obstetric indication. Emergency cesarean sections are performed in the cases of progressive dissection and urgent obstetric indication. General anesthesia was induced with fentanyl and midazolam to minimize cardiovascular response to tracheal intubation. We emphasize that evaluation of cardiovascular status and multidisciplinary approach are the key in the anesthetic management of parturients with Marfan syndrome.     

Anesthetic management of patients with pulmonary hypertension

Advances in the treatment of patients with chronic pulmonary hypertension have greatly improved their functional status and longevity, and increasing numbers of these complex patients are presenting for elective noncardiac surgery. In this communication we will briefly review the classification and pathophysiology of pulmonary hypertension, summarize outpatient pharmacotherapy approaches, and discuss the perioperative preparation and management of these complex patients. With an understanding of the underlying pathophysiology of the disease and pharmacology of these new therapies, combined with careful perioperative planning and care, these patients can safely undergo elective surgical procedures.     

Anesthetic management of a patient with tetra-amelia

A 52-year-old man with Burger disease was admitted for hemorrhoidectomy. He lost upper and lower limbs 19 years earlier. We could not monitor his blood pressure with noninvasive technique. Bilateral superficial temporal arteries were not palpable. In the operating room, the external jugular vein was cannulated and an electrocardilgram and oxygen saturation was monitored. Anesthesia was induced with spinal anesthesia of 0.5% hyperbaric bupivacaine. His carotid artery was palpable and heart rate, oxygen saturation and his consciousness were stable during operation. He had an uneventful intra- and post-operative course. Preoperative evaluation of surgery and monitoring may be needed in patients with tetra-amelia.     

Anesthetic management of a patient with oculopharyngodistal-myopathy

Oculopharyngodistal-myopathy (OPDM) is an autosomal dominant, heredofamilial myopathy accompanied with slowly progressive ptosis and extraocular palsy, and weakness of the masseter, facial, and bulbar muscles, as well as distal involvement of the limbs starting around 40 years of age or later. A 54-year-old female with OPDM underwent resection of the uterus for uterus body cancer. We speculated the patient might be at the risk of aspiration pneumonia, prolonged respiratory depression, and malignant hyperthermia, and chose spinal and epidural anesthesia. The operation was performed successfully and the patient was discharged uneventfully.     

Anesthetic management of two patients with polymyositis

We report anesthetic experience of two patients suffering from polymyositis. The first case is a 56 year old woman who underwent tympanoplasty for cholesteatoma of the middle ear. Anesthesia was induced with thiopental and deepened with oxygen-nitrous oxide and sevoflurane. No muscle relaxant was used for endotracheal intubation and for maintaining anesthesia. Another is a 61 year old man who underwent open reduction and internal fixation for condyle fracture of the tibia. Epidural catheter was inserted at L 3-L 4. Epidural blockade was established with 2% mepivacaine, and sedation was achieved by intravenous midazolam. Concerning the anesthetic management of a patient with polymyositis, there are some informations on the appropriate use of muscle relaxants. It is generally believed that the patient is sensitive to nondepolarizing muscle relaxants and the use of antagonist drug (reversal) may cause muscle weakness, severe dysrhythmia, et al. Therefore we think it is appropriate to manage such a patient without muscle relaxants.     

Anesthetic management of a parturient with hyperhomocysteinemia

High plasma levels of homocysteine are associated with an increased risk for thromboembolic events. Neuraxial anesthesia techniques may be relatively contraindicated in anticoagulated patients, and nitrous oxide may exacerbate the condition by inhibiting the conversion of homocysteine to methionine. We describe the anesthetic implications and management of a patient with hyperhomocysteinemia undergoing an nonemergent cesarean delivery.