- Email: [email protected]
CYP11B1 causing 11β-hydroxylase deficiency in Chinese patients with congenital adrenal hyperplasia
Correspondence
431 BB to achieve successful one-lung ventilation and protection in patients with continuous lung bleeding.
Details of authors’ contributions SM and NK performed critical management of the case and wrote the manuscript; TM prepared the manuscript and provided critical comments and final approval.
Patient consent Written consent was obtained from the patient for the publication of this report. Figure
Combined application of a DLT and BB.
McGRATH MAC video laryngoscope (McGRATH; Aircraft Medical Ltd, UK) and tracheal intubation with a 37F left double-lumen tracheal tube (DLT) (Bronchocath; Smith Medical, USA). We guided the bronchial lumen of the DLT to the left bronchus under fiberoptic bronchoscope guidance and inflated the bronchial cuff. Next, we inserted a BB (Coopdech Endobronchial Blocker Tube; Daiken Medical, Japan) from the tracheal lumen of the DLT and inflated the cuff in the left bronchus under fiberoptic bronchoscope guidance (Figure). During right upper lobectomy, nonnegligible amount of blood was aspirated from the inner lumen of the BB. Furthermore, there was no visible blood inflow in the left bronchus. Right upper lobectomy was performed uneventfully with the patient in the left lateral position, with no oxygenation or ventilation trouble. The patient was extubated in the operation room with no signs of bloody sputum or hemoptysis.
2. Discussion Surgical lung resection for intractable infection caused by fungus or resistant bacteria such as M abscessus is the last resort [1,2]. However, anesthetic management is often difficult when hemoptysis is also present. During anesthesia induction or lobectomy, the blood may flow from the infected lung to the ventilated lung, leading to oxygenation or ventilation failure and poor outcome. To avoid this risk, we kept the patient in the right-tilted position during anesthesia induction so as to block blood inflow from the continuously bleeding lung. To protect the ventilated lung, we used a DLT in combination with BB. With this technique, we were able to protect the ventilated lung by 2 cuffs, that is, the bronchial cuff of the DLT in the left bronchus and the BB cuff in the right bronchus. Furthermore, this allowed drainage of blood from the infected lung via the inner lumen of the BB. A DTB can be used in combination with a
Sayuri Matsunami, MD (Resident) Nobuyasu Komasawa, MD, PhD (Assistant Professor)* Toshiaki Minami, MD, PhD (Professor and Chief) Department of Anesthesiology, Osaka Medical College *Corresponding author at: Nobuyasu Komasawa, MD, PhD Department of Anesthesiology, Osaka Medical College Daigaku-machi 2-7, Takatsuki, Osaka 569-8686, Japan Tel.: +81 72 683 2368; fax: +81 72 684 6552 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.03.033
References [1] Theodore S, Liava'a M, Antippa P, Wynne R, Grigg A, Slavin M, et al. Surgical management of invasive pulmonary fungal infection in hematology patients. Ann Thorac Surg 2009;87:1532-8. [2] Shiraishi Y. Surgical treatment of nontuberculous mycobacterial lung disease. Gen Thorac Cardiovasc Surg 2014;62:475-80.
Is prehydration necessary for cesarean delivery in women with Fontan repair under epidural anesthesia?
In a recent article, Mathney and colleagues [1] presented a case wherein a woman with status post–Fontan procedure successfully underwent cesarean delivery under epidural anesthesia. The patient received a Fontan surgery in her younger days, and her physiology was described as classic Fontan in which pulmonary blood flow was entirely passive. We learned a lot from this article, but we think prehydration is unnecessary for this patient whose New York Heart Association's status had declined to class III. For a patient with the Fontan circulation, the goals of anesthesia are to maintain blood flow through the lungs and total cardiac output (CO) and especially to avoid an increase in pulmonary vascular resistance (PVR) [2]. Intubation and positive end-expiratory pressure may increase PVR,
432 and this may militate against choosing general anesthesia for these cases. Epidural anesthesia is considered the preferred anesthetic technique for those patients because it is the least likely to interfere with PVR and ventricular function [3]. But epidural anesthesia can cause a sympathetic block and may also reduce preload and CO. This situation, in turn, will reduce the pressure gradient across the pulmonary vasculature. So the patient was prehydrated with approximately 1000 mL of crystalloid to increase central venous pressure. We think that prehydration is unnecessary for this patient. On one hand, during the course of pregnancy, blood volume slowly increases by 40% to 50% and CO should increase approximately 40% [2]. The patient had a left ventricular ejection fraction of 33% and had a bad left ventricular function with shortness of breath after walking 1 block. So the main problem of this patient is left ventricular dysfunction caused by excessive preload. Inotropic, vasodilator, and diuretic drugs may be appropriate for this patient. We think that it is effective to treat this patient with milrinone, which is a positive inotrope and vasodilator with little chronotropic activity. Prehydration would lead to elevated left ventricular end-diastolic pressure and left atrial pressure, subsequently necessitating even higher right atrial pressures to maintain a gradient. On the other hand, left uterine displacement and slow titration of epidural anesthetics are especially important to avoid hypotensive episodes in lying-in women under epidural anesthesia. If hypotension still occurred after the above treatment, our management would have included fluid administration and administration of an inotropic agent. Fluid management should be guided by central venous pressure and invasive arterial monitoring instead of experience. Inotropic agent should use those which both increase cardiac contractility and decrease systemic vascular resistance, such as dobutamine, while avoiding vasopressors that may increase PVR. Yongxin Liang, MD Haichen Chu, MD Shiduan Wang, MD* Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China, 276000 ⁎Corresponding author. Department of Anesthesiology The Affiliated Hospital of Qingdao University, 16 Jiangsu Rd Qingdao, China, 276000. Tel.: +86 053282912515 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.03.032
References [1] Mathney E, Beilin Y. Successful epidural anesthesia for cesarean delivery in a woman with Fontan repair. J Clin Anesth 2015;27:60-2. [2] DiSessa TG, Child JS, Perloff JK, Wu L, Williams RG, Laks H, et al. Systemic venous and pulmonary arterial flow patterns after Fontan’s procedure for tricuspid atresia or single ventricle. Circulation 1984;70:898-902. [3] Hosking MP, Beynen FM. The modified Fontan procedure: physiology and anesthetic implications. J Cardiothorac Vasc Anesth 1992;6:465-75.
Correspondence On table extubation after emergency thoracotomy for mediastinal mass in a neonate To the Editor: Mediastinal mass in neonate poses significant risk of cardiovascular and respiratory compromise during surgery [1]. We present a case of a neonate posted for emergency thoracotomy for a mediastinal mass causing respiratory compromise. A 15-day-old term neonate was admitted in our hospital for tachypnea and respiratory distress. On evaluation, a mediastinal neuroblastoma causing compression of lungs was found to be the cause of respiratory difficulty. Ultrasonographyguided biopsy revealed a round cell tumor, and a contrast enhanced computed tomographic scan (CECT) chest revealed a 6 × 8 cm mass compressing the lung (Figure); however, computed tomographic scan did not comment about compression of the major bronchi or vessel. On the third day of hospital stay, for increasing respiratory distress and oxyhemoglobin desaturation, the child was intubated and kept on mechanical ventilation. However, in view of increasing oxygen requirement and peak airway pressure, the child was scheduled for an emergency thoracotomy. In the operating room, after attaching routine monitors, we secure a 24-G right radial arterial cannula. Anesthesia was induced by 5 mg intravenous (IV) ketamine. We maintained spontaneous ventilation in that child, and ventilation was assisted manually. Anesthesia was maintained with air— oxygen and sevoflurane. Fraction of inspired oxygen was kept around 0.6-0.7 targeting an oxygen saturation as measured by pulse oximetry N 92%. We paralyzed the child just at the time of opening of pleura by 0.6-mg atracurium. There after, the child was ventilated on pressure control ventilation mode with a peak airway pressure of 25 cm H2O and respiratory rate of 30-35/min; we were able to maintain an end tidal carbon dioxide of 50-55 mm Hg. During tumor manipulation, one episode of bradycardia (heart rate (HR) b 50) with sudden fall in end tidal carbon dioxide (EtCO2) was noted, which was managed with atropine of 90 μg and fluid boluses. Immediately after tumor resection, there was sudden loss of 70-80 ml and was replaced by 60-mL packed red blood cell (PRBC). At this point, the airway pressures and fraction of inspired oxygen requirement came down significantly, and compliance improved. Rest of the surgery was uneventful, and total duration was 40 minutes. At the time of thoracotomy closure, intercostal nerve block was given by the surgeon with 3 mL 0.2% ropivacaine. As the tumor was attached with the lower lobe of the lung, a portion of the lower lobe of the lung was also excised along with the tumor. As the surgeon had to suture lung parenchyma and bronchus, we decided to extubate the child as early as possible. During chest wall closure, IV paracetamol was given at a dose of 10 mg/kg. We did not use any opioid thereafter, and residual neuromuscular blockade was reversed with
431 BB to achieve successful one-lung ventilation and protection in patients with continuous lung bleeding.
Details of authors’ contributions SM and NK performed critical management of the case and wrote the manuscript; TM prepared the manuscript and provided critical comments and final approval.
Patient consent Written consent was obtained from the patient for the publication of this report. Figure
Combined application of a DLT and BB.
McGRATH MAC video laryngoscope (McGRATH; Aircraft Medical Ltd, UK) and tracheal intubation with a 37F left double-lumen tracheal tube (DLT) (Bronchocath; Smith Medical, USA). We guided the bronchial lumen of the DLT to the left bronchus under fiberoptic bronchoscope guidance and inflated the bronchial cuff. Next, we inserted a BB (Coopdech Endobronchial Blocker Tube; Daiken Medical, Japan) from the tracheal lumen of the DLT and inflated the cuff in the left bronchus under fiberoptic bronchoscope guidance (Figure). During right upper lobectomy, nonnegligible amount of blood was aspirated from the inner lumen of the BB. Furthermore, there was no visible blood inflow in the left bronchus. Right upper lobectomy was performed uneventfully with the patient in the left lateral position, with no oxygenation or ventilation trouble. The patient was extubated in the operation room with no signs of bloody sputum or hemoptysis.
2. Discussion Surgical lung resection for intractable infection caused by fungus or resistant bacteria such as M abscessus is the last resort [1,2]. However, anesthetic management is often difficult when hemoptysis is also present. During anesthesia induction or lobectomy, the blood may flow from the infected lung to the ventilated lung, leading to oxygenation or ventilation failure and poor outcome. To avoid this risk, we kept the patient in the right-tilted position during anesthesia induction so as to block blood inflow from the continuously bleeding lung. To protect the ventilated lung, we used a DLT in combination with BB. With this technique, we were able to protect the ventilated lung by 2 cuffs, that is, the bronchial cuff of the DLT in the left bronchus and the BB cuff in the right bronchus. Furthermore, this allowed drainage of blood from the infected lung via the inner lumen of the BB. A DTB can be used in combination with a
Sayuri Matsunami, MD (Resident) Nobuyasu Komasawa, MD, PhD (Assistant Professor)* Toshiaki Minami, MD, PhD (Professor and Chief) Department of Anesthesiology, Osaka Medical College *Corresponding author at: Nobuyasu Komasawa, MD, PhD Department of Anesthesiology, Osaka Medical College Daigaku-machi 2-7, Takatsuki, Osaka 569-8686, Japan Tel.: +81 72 683 2368; fax: +81 72 684 6552 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.03.033
References [1] Theodore S, Liava'a M, Antippa P, Wynne R, Grigg A, Slavin M, et al. Surgical management of invasive pulmonary fungal infection in hematology patients. Ann Thorac Surg 2009;87:1532-8. [2] Shiraishi Y. Surgical treatment of nontuberculous mycobacterial lung disease. Gen Thorac Cardiovasc Surg 2014;62:475-80.
Is prehydration necessary for cesarean delivery in women with Fontan repair under epidural anesthesia?
In a recent article, Mathney and colleagues [1] presented a case wherein a woman with status post–Fontan procedure successfully underwent cesarean delivery under epidural anesthesia. The patient received a Fontan surgery in her younger days, and her physiology was described as classic Fontan in which pulmonary blood flow was entirely passive. We learned a lot from this article, but we think prehydration is unnecessary for this patient whose New York Heart Association's status had declined to class III. For a patient with the Fontan circulation, the goals of anesthesia are to maintain blood flow through the lungs and total cardiac output (CO) and especially to avoid an increase in pulmonary vascular resistance (PVR) [2]. Intubation and positive end-expiratory pressure may increase PVR,
432 and this may militate against choosing general anesthesia for these cases. Epidural anesthesia is considered the preferred anesthetic technique for those patients because it is the least likely to interfere with PVR and ventricular function [3]. But epidural anesthesia can cause a sympathetic block and may also reduce preload and CO. This situation, in turn, will reduce the pressure gradient across the pulmonary vasculature. So the patient was prehydrated with approximately 1000 mL of crystalloid to increase central venous pressure. We think that prehydration is unnecessary for this patient. On one hand, during the course of pregnancy, blood volume slowly increases by 40% to 50% and CO should increase approximately 40% [2]. The patient had a left ventricular ejection fraction of 33% and had a bad left ventricular function with shortness of breath after walking 1 block. So the main problem of this patient is left ventricular dysfunction caused by excessive preload. Inotropic, vasodilator, and diuretic drugs may be appropriate for this patient. We think that it is effective to treat this patient with milrinone, which is a positive inotrope and vasodilator with little chronotropic activity. Prehydration would lead to elevated left ventricular end-diastolic pressure and left atrial pressure, subsequently necessitating even higher right atrial pressures to maintain a gradient. On the other hand, left uterine displacement and slow titration of epidural anesthetics are especially important to avoid hypotensive episodes in lying-in women under epidural anesthesia. If hypotension still occurred after the above treatment, our management would have included fluid administration and administration of an inotropic agent. Fluid management should be guided by central venous pressure and invasive arterial monitoring instead of experience. Inotropic agent should use those which both increase cardiac contractility and decrease systemic vascular resistance, such as dobutamine, while avoiding vasopressors that may increase PVR. Yongxin Liang, MD Haichen Chu, MD Shiduan Wang, MD* Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China, 276000 ⁎Corresponding author. Department of Anesthesiology The Affiliated Hospital of Qingdao University, 16 Jiangsu Rd Qingdao, China, 276000. Tel.: +86 053282912515 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.03.032
References [1] Mathney E, Beilin Y. Successful epidural anesthesia for cesarean delivery in a woman with Fontan repair. J Clin Anesth 2015;27:60-2. [2] DiSessa TG, Child JS, Perloff JK, Wu L, Williams RG, Laks H, et al. Systemic venous and pulmonary arterial flow patterns after Fontan’s procedure for tricuspid atresia or single ventricle. Circulation 1984;70:898-902. [3] Hosking MP, Beynen FM. The modified Fontan procedure: physiology and anesthetic implications. J Cardiothorac Vasc Anesth 1992;6:465-75.
Correspondence On table extubation after emergency thoracotomy for mediastinal mass in a neonate To the Editor: Mediastinal mass in neonate poses significant risk of cardiovascular and respiratory compromise during surgery [1]. We present a case of a neonate posted for emergency thoracotomy for a mediastinal mass causing respiratory compromise. A 15-day-old term neonate was admitted in our hospital for tachypnea and respiratory distress. On evaluation, a mediastinal neuroblastoma causing compression of lungs was found to be the cause of respiratory difficulty. Ultrasonographyguided biopsy revealed a round cell tumor, and a contrast enhanced computed tomographic scan (CECT) chest revealed a 6 × 8 cm mass compressing the lung (Figure); however, computed tomographic scan did not comment about compression of the major bronchi or vessel. On the third day of hospital stay, for increasing respiratory distress and oxyhemoglobin desaturation, the child was intubated and kept on mechanical ventilation. However, in view of increasing oxygen requirement and peak airway pressure, the child was scheduled for an emergency thoracotomy. In the operating room, after attaching routine monitors, we secure a 24-G right radial arterial cannula. Anesthesia was induced by 5 mg intravenous (IV) ketamine. We maintained spontaneous ventilation in that child, and ventilation was assisted manually. Anesthesia was maintained with air— oxygen and sevoflurane. Fraction of inspired oxygen was kept around 0.6-0.7 targeting an oxygen saturation as measured by pulse oximetry N 92%. We paralyzed the child just at the time of opening of pleura by 0.6-mg atracurium. There after, the child was ventilated on pressure control ventilation mode with a peak airway pressure of 25 cm H2O and respiratory rate of 30-35/min; we were able to maintain an end tidal carbon dioxide of 50-55 mm Hg. During tumor manipulation, one episode of bradycardia (heart rate (HR) b 50) with sudden fall in end tidal carbon dioxide (EtCO2) was noted, which was managed with atropine of 90 μg and fluid boluses. Immediately after tumor resection, there was sudden loss of 70-80 ml and was replaced by 60-mL packed red blood cell (PRBC). At this point, the airway pressures and fraction of inspired oxygen requirement came down significantly, and compliance improved. Rest of the surgery was uneventful, and total duration was 40 minutes. At the time of thoracotomy closure, intercostal nerve block was given by the surgeon with 3 mL 0.2% ropivacaine. As the tumor was attached with the lower lobe of the lung, a portion of the lower lobe of the lung was also excised along with the tumor. As the surgeon had to suture lung parenchyma and bronchus, we decided to extubate the child as early as possible. During chest wall closure, IV paracetamol was given at a dose of 10 mg/kg. We did not use any opioid thereafter, and residual neuromuscular blockade was reversed with