Severe portopulmonary hypertension (PPHT) is considered a contraindication for liver transplantation (LT) because of the associated high mortality and poor prognosis. We report the case of a 57-year-old cirrhotic woman with severe PPHT (mean pulmonary artery pressure [mPAP] > 65 mmHg), who underwent a successful living donor LT. Intra-operative use of inhaled iloprost, milrinone, dobutamine, and postoperative use of inhaled nitric oxide and oral sildenafil failed to lower the pulmonary artery pressure (PAP). The patient responded only to nitroglycerin and drainage of massive ascites. Meticulous intra-operative volume control, which included minimizing blood loss and subsequent transfusion, was carried out. The use of vasopressors, which may have elevated the PAP, was strictly restricted. Intra-operative PAP did not show an increase, and the hemodynamics was maintained within relatively normal range, compared to the preoperative state. The patient was discharged without any complications or related symptoms.
Ascites ; Dobutamine ; Drainage ; Female ; Hemodynamics ; Humans ; Hypertension* ; Iloprost ; Liver Transplantation* ; Living Donors ; Middle Aged ; Milrinone ; Mortality ; Nitric Oxide ; Nitroglycerin ; Prognosis ; Pulmonary Artery ; Reference Values ; Sildenafil Citrate

A reninoma is an uncommon, benign, renin-secreting juxtaglomerular cell tumor that causes secondary hypertension in young patients. This hypertension is treated by tumor resection. Except for increased levels of plasma renin and angiotensin I and II, the other physical and laboratory examinations and electrocardiographs were within normal limits upon admission of a 19-year-old woman with a reninoma. For percutaneous computed tomography-guided radiofrequency ablation, general anesthesia was induced by thiopental sodium and rocuronium bromide and maintained with servoflurane (2-4 vol%) and oxygen. The operation ended uneventfully in hemodynamic stability. However, the patient complained of dizziness while sitting 5 hours after the operation, and hypotension was diagnosed. After aggressive normal saline (1 L) infusion over 30 min, the hypotension was corrected and the patient recovered without any other surgical complications. Here, we report the anesthetic management of a patient who underwent percutaneous computed tomography-guided radiofrequency ablation for reninoma destruction, particularly focusing on postoperative hypotension.
Anesthesia, General ; Angiotensin I ; Catheter Ablation* ; Dizziness ; Electrocardiography ; Female ; Hemodynamics ; Humans ; Hypertension ; Hypotension ; Oxygen ; Plasma ; Renin ; Thiopental ; Young Adult

Intracardiac thrombosis is an infrequent and fatal complication in patients with an inserted pacemaker. A patient with an inserted pacemaker scheduled for ureter stone removal experienced cardiac arrest and cardiopulmonary resuscitation under general anesthesia. Echocardiography showed multiple intracardiac thrombi. Preoperative diagnostic workup including echocardiography for the detection of pacemaker lead thrombus, and the need for anticoagulation should be considered in patients with an inserted pacemaker and high-risk factors for thrombosis.
Anesthesia, General ; Cardiopulmonary Resuscitation ; Echocardiography ; Heart Arrest ; Humans ; Lithotripsy* ; Thromboembolism* ; Thrombosis ; Ureter*

Thrombus-in-transit appears to increase the risk of mortality compared to pulmonary embolism alone and can require alteration in therapeutic plan. We present the case of a biatrial thromboembolus caught in transit across a patent foramen ovale diagnosed by intraoperative transesophageal echocardiogram in a 69-year-old female with acute pulmonary embolism and subsequent acute cerebral infarction. We suggest that echocardiography should be performed in a patient with suspected pulmonary thromboembolism to evaluate right heart function and diagnose emboli in transit.
Aged ; Cerebral Infarction ; Echocardiography ; Female ; Foramen Ovale, Patent* ; Heart ; Humans ; Mortality ; Pulmonary Embolism* ; Thrombosis*

BACKGROUND: Ventilator-induced lung injury (VILI) sustained during mechanical ventilator support is still a cause of a high rate of morbidity and mortality in intensive care units and in operating rooms. VILI is characterized by pulmonary inflammation that appears to be mediated by proinflammatory cytokines. This study investigates whether the volatile anesthetic sevoflurane has an anti-inflammatory effect that attenuates VILI. METHODS: Twenty one male rabbits were anesthetized and were mechanically ventilated with 50% oxygen at a peak inspiratory pressure (PIP) of 10 cmH2O, I : E ratio of 1 : 4, and positive end expiratory pressure of 5 cmH2O. All animals were randomly assigned to one of three groups that were ventilated for 5 h with 10 cmH2O of PIP (Sham group, n = 7); 30 cmH2O of PIP (Control group, n = 7); or 30 cmH2O of PIP and 0.8 vol% sevoflurane (Sevoflurane group, n = 7). The wet/dry weight (W/D) ratio and histopathology of the lung; concentration of interleukin-8 (IL-8) in the bronchoalveolar lavage fluid; and activation of extracellular signal-regulated kinases (ERK) 1/2, p38 mitogen-activated protein kinase, and Akt were measured in the lung tissue after completing the protocol. RESULTS: Histopathology indicated that the sevoflurane group showed fewer inflammatory cells and architectural changes than the control group did. The W/D ratio [(5.36 +/- 0.13) versus (6.61 +/- 0.20)], expression of IL-8 [(144.08 +/- 14.61) versus (228.56 +/- 15.13) pg/ml] and phosphorylation of ERK1/2 and Akt decreased significantly in the sevoflurane group relative to the control group. CONCLUSIONS: Sevoflurane attenuates VILI in rabbits mainly by inhibiting expression of IL-8, and Sevoflurane-induced inhibition of phosphorylated ERK1/2 and Akt might be a possible pathway for protection.
Animals ; Bronchoalveolar Lavage Fluid ; Cytokines ; Extracellular Signal-Regulated MAP Kinases ; Humans ; Intensive Care Units ; Interleukin-8 ; Lung ; Male ; Mortality ; Operating Rooms ; Oxygen ; Phosphorylation ; Pneumonia ; Positive-Pressure Respiration ; Protein Kinases ; Rabbits ; Signal Transduction* ; Ventilator-Induced Lung Injury* ; Ventilators, Mechanical

BACKGROUND: Magnesium, ropivacaine, gentamicin, and rocuronium block neuromuscular (NM) transmission by different mechanisms. Therefore, concurrent administration of these agents may induce prolonged muscle paralysis via synergistic interaction. This study investigated the efficacy and safety of NM block caused by the administration of high concentrations of magnesium in combination with ropivacaine, gentamicin, and rocuronium. METHODS: Eighty-three left phrenic nerve-hemidiaphragms from male SD rats (150-250 g) were hung in Krebs solution. Three consecutive single twitch tension (ST, 0.1 Hz) and one tetanic tension (TT, 50 Hz for 1.9 s) were obtained before drug application and at each new drug concentration. The concentration of MgCl2 and MgSO4 in Krebs solution was increased until an 80 to 90% reduction in ST was reached. To test the effects of combinations of NM agents, a Krebs solution was premixed with MgCl2 alone, MgCl2 and ropivacaine, or MgCl2, ropivacaine, and gentamicin. The concentration of ropivacaine, gentamicin, or rocuronium was then progressively increased until an 80 to 90% reduction in ST was reached. The effective concentrations were estimated with a probit model. RESULTS: The potency of MgCl2 was greater than that of MgSO4, and pretreatment with MgCl2 increased the potency of gentamicin and rocuronium. Unexpectedly, MgCl2 did not potentiate ropivacaine, and the potency of gentamicin and rocuronium failed to show an increase when premixed with 0.5 microM ropivacaine. CONCLUSIONS: The concomitant administration of high concentrations of magnesium and ropivacaine together with clinically relevant concentrations of gentamicin or rocuronium potentiated NM blockade but not with clinically relevant concentrations of ropivacaine.
Animals ; Gentamicins* ; Humans ; Magnesium Chloride ; Magnesium* ; Male ; Neuromuscular Blockade* ; Paralysis ; Rats

BACKGROUND: We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. METHODS: Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 microg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. RESULTS: Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. CONCLUSIONS: Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.
Anesthesia* ; Ear, Middle* ; Humans ; Ketorolac ; N-Methylaspartate ; Nefopam* ; Pain, Postoperative ; Postoperative Period ; Tympanoplasty

BACKGROUND: The old age population, including the very old aged (> or = 85 years), is rapidly increasing, and femur neck fracture from accidents is commonly seen in the elderly. Use of bone cement during bipolar hemiarthroplasty can cause bone cement implantation syndrome. METHODS: This study was prospectively conducted on the elderly who were scheduled to undergo elective cemented bipolar hemiarthroplasty under spinal anesthesia. Patients were divided into 2 groups: the old age (65-84 years) and very old age groups (> or = 85 years). Hemodynamic parameters were recorded at the following time points: the start of the operation, femoral reaming, cement insertion, every 2 minutes after cement insertion for 10 minutes, femoral joint reduction, and the end of operation. When hypotension occurred, ephedrine was given. RESULTS: Sixty-five patients in the old age group and 32 patients in the very old age group were enrolled. Mean ages were 78.9 and 89.4 years, respectively, in the old age and very old age groups. The very old age group showed constantly decreased levels of cardiac index and stroke volume from cementing until the end of the operation compared to the old age group. To maintain hemodynamic stability after cement insertion, the requirement of ephedrine was higher in the very old age group than in the old age group (13.52 +/- 7.76 vs 8.65 +/- 6.38 mg, P = 0.001). CONCLUSIONS: Bone cement implantation during bipolar hemiarthroplasty may cause more prominent hemodynamic changes in very elderly patients. Careful hemodynamic monitoring and management are warranted in very elderly patients undergoing cemented bipolar hemiarthroplasty.
Aged ; Anesthesia, Spinal* ; Bone Cements ; Ephedrine ; Femoral Neck Fractures ; Hemiarthroplasty* ; Hemodynamics* ; Humans ; Hypotension ; Joints ; Prospective Studies ; Stroke Volume

BACKGROUND: The aim of this study was to evaluate the sedative effect of dexmedetomidine (DEX) added to ropivacaine for supraclavicular brachial plexus block (BPB) using the bispectral index (BIS). METHODS: Sixty patients (American Society of Anesthesiologists physical status 1 or 2, aged 20-65 years) undergoing wrist and hand surgery under supraclavicular BPB were randomly allocated to two groups. Ultrasound-guided supraclavicular BPB was performed with 40 ml of ropivacaine 0.5% and 1 microg/kg of DEX (Group RD) or 0.01 ml/kg of normal saline (Group R). The primary endpoint was the BIS change during 60 min after block. The secondary endpoint was the change in the mean arterial blood pressure (MAP), heart rate (HR), and SpO2 and the onset time and duration of the sensory and motor block. RESULTS: In Group RD, the BIS decreased significantly until 30 min after the block (69.2 +/- 13.7), but remained relatively constant to 60 min (63.8 +/- 15.3). The MAP, HR and BIS were significantly decreased compared with Group R. The onset time of the sensory and motor block were significantly faster in Group RD than in Group R. The duration of the sensory and motor block were significantly increased in Group RD. CONCLUSIONS: DEX added to ropivacaine for brachial plexus block induced sedation that corresponds to a BIS value of 60 from which patients are easily awakened in a lucid state. In addition, perineural DEX shortened the onset time and prolonged the duration of the sensory and motor blocks.
Arterial Pressure ; Brachial Plexus* ; Dexmedetomidine* ; Hand ; Heart Rate ; Humans ; Hypnotics and Sedatives ; Wrist

BACKGROUND: The proper cuff pressure is important to prevent complications related to the endotracheal tube (ETT). We evaluated the change in ETT cuff pressure by changing the position from supine to prone without head movement. METHODS: Fifty-five patients were enrolled and scheduled for lumbar spine surgery. Neutral angle, which was the angle on the mandibular angle between the neck midline and mandibular inferior border, was measured. The initial neutral pressure of the ETT cuff was measured, and the cuff pressure was subsequently adjusted to 26 cmH2O. Flexed or extended angles and cuff pressure were measured in both supine and prone positions, when the patient's head was flexed or extended. Initial neutral pressure in prone was compared with adjusted neutral pressure (26 cmH2O) in supine. Flexed and extended pressure were compared with adjusted neutral pressure in supine or prone, respectively. RESULTS: There were no differences between supine and prone position for neutral, flexed, and extended angles. The initial neutral pressure increased after changing position from supine to prone (26.0 vs. 31.5 +/- 5.9 cmH2O, P < 0.001). Flexed and extended pressure in supine were increased to 38.7 +/- 6.7 (P < 0.001) and 26.7 +/- 4.7 cmH2O (not statistically significant) than the adjusted neutral pressure. Flexed and extended pressure in prone were increased to 40.5 +/- 8.8 (P < 0.001) and 29.9 +/- 8.7 cmH2O (P = 0.002) than the adjusted neutral pressure. CONCLUSIONS: The position change from supine to prone without head movement can cause a change in ETT cuff pressure.
Head Movements ; Head* ; Humans ; Neck ; Prone Position ; Spine