RESUMEN
A 68-year-old woman with anti-phospholipid antigen syndrome (APS) was proposed to undergo partial pulmonary resection for lung cancer. She suffered from mild cerebellar ataxia. Exercised 201Tl myocardial scintigraphy was performed due to abnormal Q wave in preoperative electrocardiography and showed old myocardial infarction in inferior-to-posterior area without myocardial ischemia. Cardiac function was marginally decreased in cardiac echographic evaluation. Arterial thrombosis by APS might cause cerebellar ataxia and myocardial infarction. Low molecular weight heparin (LMWH) was continuously infused from 1 hour prior to arrival in an operation room. Elastic stockings (ES) were worn from the morning of the operation in combination with the use of intermittent pneumatic compression apparatus (IPC). Significant bleeding was not observed perioperatively. Hypothermia was avoided by forced-air-warming therapy. She was transferred to ICU after the end of the operation. She was returned to her ward without IPC on the first postoperative day. Warfarin was given with the beginning of ambulation on the second postoperative day to keep PT-INR about 2. On the third postoperative day LMWH was discontinued and ES were taken off. The postoperative course was uneventful.
Asunto(s)
Anestesia General , Síndrome Antifosfolípido/complicaciones , Heparina de Bajo-Peso-Molecular/administración & dosificación , Neumonectomía , Embolia Pulmonar/prevención & control , Anciano , Anestesia General/métodos , Femenino , Humanos , Neoplasias Pulmonares/cirugía , Atención PerioperativaRESUMEN
We experienced perioperative management for excision of a huge sternal chondrosarcoma squeezing the heart. A 46-year-old woman could not sleep due to dyspnea for 6 months. Dyspnea increased in the right decubitus and disappeared in the left decubitus. This suggested that the heart was squeezing the tumor. MRI and echocardiography revealed no invasion to the heart. Surgical removal was proposed. Anesthesia was induced with propofol and fentanyl. As this tumor composed of bone-like tissue and was tightly connected with thoracic cage, we thought that the use of muscle relaxant at the induction of anesthesia would not cause cardiovascular collapse and ventilation insufficiency even if the tumor was huge. Vecuronium was administered to facilitate endotracheal intubation. Hemodynamic variables were stable and mask ventilation was uneventful. Anesthesia was maintained with propofol, sevoflurane, supplemental dose of fentanyl and epidural anesthesia. The tumor had invaded the myocardium and was successfully flaked off from the myocardium without using any assisted devices. The tumor was excised including thoracic wall (sternum and parts of 3rd to 12th ribs, 20 cm in diameter). Thoracoplasty was performed using Marlex Mesh. Muscle relaxant was reversed after the end of the operation. Respiration was stable without flail chest. Endotracheal tube was successfully removed in the operation room. The postoperative course was uneventful.
Asunto(s)
Anestesia General/métodos , Neoplasias Óseas/cirugía , Condrosarcoma/cirugía , Neoplasias Cardíacas/cirugía , Esternón , Anestesia Epidural , Neoplasias Óseas/patología , Condrosarcoma/patología , Femenino , Neoplasias Cardíacas/patología , Humanos , Intubación Intratraqueal , Persona de Mediana Edad , Invasividad Neoplásica , Presión , Propofol , Mallas Quirúrgicas , Bromuro de VecuronioRESUMEN
We experienced anesthetic management of two patients with hypertrophic obstructive cardiomyopathy (HOCM) for percutaneous transluminal septal myocardial ablation (PTSMA). PTSMA had been performed more than a year earlier in both cases, and symptoms and exercise tolerance were improved after PTSMA. Laparotomy for suspected ovarian cancer in one patient and thoracotomy for metastatic lung cancer in the other patient were proposed. Preoperative echocardiography showed reduced left ventricular outflow tract pressure gradient (from 90 mmHg before PTSMA to 10 mmHg and from 81 mmHg to 17 mmHg, respectively) and decreased septal wall thickness. Systolic anterior movement of mitral valve apparatus had disappeared. General anesthesia in the former and general anesthesia combined with epidural anesthesia in the latter were employed. Anesthesia was induced with propofol and fentanyl. A laryngeal mask was used to minimize hemodynamic fluctuations during induction and emergence in the former. Anesthesia was maintained with propofol, sevoflurane and supplemental fentanyl. Epidural anesthesia was also used to maintain anesthesia in the latter. The postoperative course was uneventful in each case. PTSMA for HOCM might be useful to prevent perioperative cardiac events.
Asunto(s)
Anestesia General , Cardiomiopatía Hipertrófica/cirugía , Ablación por Catéter/métodos , Anciano , Anestesia Epidural , Femenino , Fentanilo , Humanos , Laparotomía , Máscaras Laríngeas , Éteres Metílicos , Propofol , Sevoflurano , ToracotomíaRESUMEN
A small dose of dopamine has been routinely infused for hemodynamic stabilization and diuresis in patients undergoing esophagectomy and gastric tube in place until the seventh postoperative day in our hospital. The timing of discontinuing infusion of dopamine was determined by our experience. However, there was no rationale to determine the timing of discontinuing it. Therefore, eight patients with ASA physical status I or II, undergoing esophagectomy and gastric tube in place were studied to evaluate postoperative cardiac load using brain natriuretic peptide, which is a biochemical detector of left ventricular dysfunction. There were no hemodynamic and cardiac events including myocardial ischemia and infarction in any patients. The postoperative course was uneventful in all patients. Serum BNP increased gradually and significantly until the third postoperative day with increasing urine volume. Serum BNP returned to the baseline level on the fourth postoperative day. However, serum BNP was still high in 3 patients on the sixth postoperative day in spite of dopamine. We conclude that cardiac overload was recognized until the third postoperative day.
Asunto(s)
Esofagectomía , Hemodinámica , Intubación Gastrointestinal , Péptido Natriurético Encefálico/sangre , Anciano , Esofagoplastia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo PosoperatorioRESUMEN
We experienced anesthesia for partial pulmonary resection in a postpneumonectomy patient. A 59 year-old woman underwent left upper lobectomy 5 years earlier and left lower lobectomy 2 years earlier for lung cancer, respectively. Right segmental pulmonary resection was proposed for lung cancer. Preoperative examinations revealed decreased FVC (1.81 l) and FVC1 (1.57 l), and increased PaCO2 (48.4 mmHg). The patient was monitored with EKG, direct arterial pressure, central venous pressure, pulse oxymetry and expired gas analysis. Anesthesia was induced with thiopental and fentanyl, and maintained with sevoflurane, propofol and supplemental fentanyl after the establishment of epidural anesthesia. Dopamine was continuously infused due to decreased blood pressure. Then hemodynamics was stable. Operative procedure was protective. Therefore SPO2 was kept above 98% during the operation. Partial resection was performed instead of segmental resection to avoid deteriorating the postoperative quality of life. The postoperative course was uneventful.
Asunto(s)
Anestesia Epidural , Anestesia General , Neoplasias Pulmonares/cirugía , Neumonectomía/métodos , Femenino , Humanos , Persona de Mediana Edad , Factores de TiempoRESUMEN
PURPOSE: To investigate whether continuous epidural droperidol and intravenous (IV) intraoperative droperidol inhibit pruritus and postoperative nausea and vomiting (PONV) during epidural morphine analgesia. DESIGN: Randomized, double-blinded, controlled study. SETTING: Metropolitan cancer center. PATIENTS: 120 ASA physical status I and II patients undergoing thoracic or abdominal surgery with general anesthesia combined with epidural anesthesia. INTERVENTIONS: Patients received an intraoperative epidural injection of 2 mg morphine hydrochloride, followed postoperatively by a continuous epidural infusion of morphine hydrochloride 4 mg/day for 4 days. Patients were randomly allocated to four groups: Group A = control group, Group B = intraoperative single IV injection of droperidol (2.5 mg), Group C = postoperative continuous epidural droperidol infusion (2.5 mg/day), and Group D = intraoperative IV injection of droperidol (2.5 mg) and postoperative continuous epidural droperidol infusion (2.5 mg/day). MEASUREMENTS AND MAIN RESULTS: The frequency and severity of pruritus and PONV in each group were evaluated during the postoperative period. Continuous epidural infusion of droperidol significantly reduced the frequency and severity of pruritus and PONV induced by epidural morphine without causing significant side effects. Intraoperative single IV injection of droperidol was effective for PONV (p < 0.05) but not for pruritus. CONCLUSION: Postoperative epidural droperidol infusion significantly decreased both the frequency and severity of pruritus and PONV during postoperative continuous epidural morphine analgesia. IV intraoperative droperidol significantly reduced the frequency and the severity of PONV but not pruritus.