Polycythemia vera is a hematologic malignancy characterized by excessive proliferation of erythroid, myeloid and megakaryocytic elements within bone marrow, resulting in increased red cell mass, frequently leukocytosis and thrombocytosis. Patients with absolute erythrocytosis can be categorized into primary; those in whom excessive production of red cells results from a disorder intrinsic to the erythroid progenitor cells of bone marrow, or secondary; from excessive stimulation of an otherwise normal marrow by substance such as erythropoietin. Polycythemia vera is a disease process in which control prior to surgery decreases the frequency of perioperative complications. Surgery was postponed on an 61-year-old female patient found to have a hematocrit of 59%. She was phlebotomized and treated with hydroxyurea. Her hematocrit was decreased to 43%. General anesthesia was maintained with N2O-O2-enflurane after tracheal intubation. No thrombotic or bleeding problem was developed and she was discharged without complication at 14th day after operation.
Anesthesia, General ; Bone Marrow ; Erythrocyte Volume ; Erythroid Precursor Cells ; Erythropoietin ; Female ; Hematocrit ; Hematologic Neoplasms ; Hemorrhage ; Humans ; Hydroxyurea ; Intubation ; Leukocytosis ; Middle Aged ; Polycythemia Vera* ; Polycythemia* ; Shoulder Joint* ; Shoulder* ; Thrombocytosis

Intracardiac thrombus during cardiopulmonary bypass (CPB) with full heparinization is very rare but fatal. A 60-year-old woman was scheduled for aortic and mitral valve repairs with a maze procedure for mixed aortic and mitral valvular heart disease with atrial fibrillation. Preoperative transthoracic echocardiography and cardiac computed tomography showed moderate aortic regurgitation and moderate mitral stenosis with regurgitation. There was no intracardiac thrombus. Aortic and mitral valve repairs with the maze procedure were successfully performed without unexpected events. During CPB weaning, a mobile hyper-echogenic mass in the left atrium was detected on transesophageal echocardiography. After cardiac arrest, it was surgically removed. On completion of the operation, weaning from CPB was accomplished uneventfully. The patient fully recovered and was discharged from the intensive care unit on her third postoperative day.
Aortic Valve Insufficiency ; Atrial Fibrillation ; Cardiopulmonary Bypass ; Echocardiography ; Echocardiography, Transesophageal ; Female ; Heart Arrest ; Heart Atria ; Heart Valve Diseases ; Heparin ; Humans ; Intensive Care Units ; Middle Aged ; Mitral Valve ; Mitral Valve Stenosis ; Thrombosis ; Weaning

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.
Aneurysm ; Aorta, Thoracic ; Brain Ischemia ; Circulatory Arrest, Deep Hypothermia Induced ; Disulfiram ; Hemodilution ; Humans ; Oximetry ; Spectrum Analysis ; Wit and Humor as Topic

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.
Aneurysm ; Aorta, Thoracic ; Brain Ischemia ; Circulatory Arrest, Deep Hypothermia Induced ; Disulfiram ; Hemodilution ; Humans ; Oximetry ; Spectrum Analysis ; Wit and Humor as Topic

No abstract available.
Heart Septal Defects, Atrial* ; Mitral Valve Stenosis* ; Myxoma*

Transesophageal echocardiography (TEE) can provide real time information about anatomic and hemodynamic state and guide management in cardiac surgery.Despite greater technical advances, TEE has artifacts and pitfalls.This report describes a 68-year-old female patient underwent mitral valve replacement and Maze operation.After the procedures, TEE found right atrial mass which did not exist before cardiopulmonary bypass.After discussing with operator, right atrium was explored because it was thought to be a thrombus attached on pulmonary arterial catheter.However, it was revealed as folding of right atrium.The pitfalls of TEE resulted in misdiagnosis and unnecessary procedure.Therefore, authors reviewed echocardiographical artifacts and pitfalls in right atrium which could be misdiagnosed.
Aged ; Artifacts ; Diagnostic Errors ; Echocardiography ; Echocardiography, Transesophageal ; Female ; Heart Atria ; Hemodynamics ; Humans ; Mitral Valve ; Thrombosis

We report a case using cerebral oxygen saturation (rCbO2) for off-pump coronary artery bypass graft (OPCAB) surgery in a patient with co-existing Moyamoya disease. The rCbO2 with the routine monitoring for OPCAB surgery were monitored intraoperatively. In spite of infusing nimodipine (0.2 microgram/kg/min) and maintaining the end-tidal CO2 tension at 35-40 mmHg, a sudden reduction in the right-side rCbO2 from the base line value of 70-80%/78-83% (Left/Right) to 70-72%/65-70% was developed during the harvesting of the vascular graft. We increased the rate of phenylephrine infusion to increase systemic and cerebral perfusion pressure, and both rCbO2 values were elevated to 80%/70% within 3 minutes. However, the preferential reduction in the right-side rCbO2 compared with the left-side value was not corrected. While suspecting cerebral ischemia due to cerebral vascular spasm, we administered nimodipine 2 mg bolus and increased infusion rate to 0.5 microgram/kg/min. Finally, the preferential rCbO2 reduction in the right-side was corrected and both rCbO2 reached 84%/91%. We concluded rCbO2 monitoring is useful for detecting an intraoperative episode of cerebral ischemia and maintaining the optimal cerebral perfusion during OPCAB surgery with Moyamoya disease.
Brain Ischemia ; Coronary Artery Bypass, Off-Pump ; Humans ; Moyamoya Disease ; Nimodipine ; Oxygen ; Perfusion ; Phenylephrine ; Spasm ; Transplants

The percutaneous transhepatic biliary drainage (PTBD) is an effective intervention as a palliative therapy for relieving a jaundice and cholangitis. It may be used in place of Endoscopic retrograde cholangiopancreatography (ERCP) in the obstructive biliary disease. Recently, by developing invasive procedures, the incidence of the complications such as bleeding and perforation has been increasing in the diagnosis and treatment of hepatobiliary disease. We report here on a case of remained drawstring after PTBD in a 85-year-old man. The patient was conducted PTBD for relieving a jaundice and cholangitis. And then the patient had complained of abdominal pain constantly. A few days later, we removed PTBD and attempted ERCP for removal of CBD stone. The ERCP showed remained drawstring around ampulla of vater and we removed it by IT knife. The drawstring was successfully removed.
Abdominal Pain ; Aged, 80 and over ; Ampulla of Vater ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Diagnosis ; Drainage* ; Hemorrhage ; Humans ; Incidence ; Jaundice ; Palliative Care

BACKGROUND: It is known that bupivacaine induce cell death in several immortalized cells. However, there is no report concerning bupivacaine-induced cell death in the primary cultured cardiomyocytes. We compared the direct cytotoxicity of local anesthetics in cardiomyocytes. Furthermore, the mechanisms of cell death were evaluated. METHODS: The myocardial cells of rat pups were cultured 3 days after seeding. The methyltetrazolium (MTT) assay was employed to quantify differences in cellular viability. To confirm apoptosis, Hoechst-propidium iodide staining, DNA fragmentation by electrophoresis and western blot analysis were performed. And to examine the mechanisms of cell death, intracellular calcium and expression levels of mitogen-activated protein kinases (MAPKs) family members were evaluated. RESULTS: Among the local anesthetics under 1 mM concentration for 18 h, only bupivacaine significantly decreased the MTT activity (P < 0.001). Bupivacaine induced cell death in a dose-responsive and time dependent manner. Cell death showed apoptotic characteristics, such as DNA fragmentation, chromatin condensation, decrease of precursor caspase-3 protein level, increased cleaved PARP, and cytochrome C release into the cytoplasm. Bupivacaine phosphorylated three major MAPKs, i.e. extracellular signal-regulated kinases (ERKs), p38 kinase and c-Jun N-terminal kinases (JNKs) stress-activated protein kinases. Administration of ERK inhibitor increase cell death, whereas inhibitors of p38 kinase and JNK decreased cell death (P < 0.05). In addition, the intracellular calcium level was approximately 4 times higher after the bupivacaine treatment (P < 0.001), which was inhibited by calcium chelators (P < 0.001). Calcium chelators inhibited expression of MAPKs. CONCLUSIONS: In bupivacaine-induced apoptosis in cardiomyocytes, intracellular calcium increase and MAPKs family plays important roles.
Anesthetics, Local ; Animals ; Apoptosis* ; Blotting, Western ; Bupivacaine ; Calcium ; Caspase 3 ; Cell Death ; Chelating Agents ; Chromatin ; Cytochromes c ; Cytoplasm ; DNA Fragmentation ; Electrophoresis ; Extracellular Signal-Regulated MAP Kinases ; Humans ; Mitogen-Activated Protein Kinases ; Myocytes, Cardiac* ; p38 Mitogen-Activated Protein Kinases* ; Phosphotransferases ; Protein Kinases ; Rats

This study aimed to investigate the analgesic effect of substance P (SP) in an animal model of neuropathic pain. An experimental model of neuropathic pain, the chronic constriction injury (CCI) model, was established using ICR mice. An intravenous (i.v.) injection of SP (1 nmole/kg) was administered to the mice to examine the analgesic effects of systemic SP on neuropathic pain. Behavioral testing and immunostaining was performed following treatment of the CCI model with SP. SP attenuated mechanical allodynia in a time-dependent manner, beginning at 1 h following administration, peaking at 1 day post-injection, and decaying by 3 days post-injection. The second injection of SP also increased the threshold of mechanical allodynia, with the effects peaking on day 1 and decaying by day 3. A reduction in phospho-ERK and glial fibrillary acidic protein (GFAP) accompanied the attenuation of mechanical allodynia. We have shown for the first time that i.v. administration of substance P attenuated mechanical allodynia in the maintenance phase of neuropathic pain using von Frey’s test, and simultaneously reduced levels of phospho-ERK and GFAP, which are representative biochemical markers of neuropathic pain. Importantly, glial cells in the dorsal horn of the spinal cord (L4–L5) of SP-treated CCI mice, expressed the anti-inflammatory cytokine, IL-10, which was not seen in vehicle saline-treated mice. Thus, i.v. administration of substance P may be beneficial for improving the treatment of patients with neuropathic pain, since it decreases the activity of nociceptive factors and increases the expression of anti-nociceptive factors.
Administration, Intravenous* ; Animals ; Behavior Rating Scale ; Biomarkers ; Constriction ; Glial Fibrillary Acidic Protein ; Humans ; Hyperalgesia* ; Interleukin-10 ; Mice ; Mice, Inbred ICR ; Models, Animal ; Models, Theoretical ; Neuralgia ; Neuroglia ; Spinal Cord ; Spinal Cord Dorsal Horn ; Substance P*