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PURPOSE: Severe hypotension caused by anesthetic administration for anesthesia induction, which might cause ischemic stroke, myocardial injury, acute kidney injury and postoperative mortality, should be prevented. Anesthesiologists are familiar with ultrasound examination of the internal jugular vein (IJV). This study aimed to clarify whether ultrasonographic IJV evaluation just before induction could predict the occurrence of such hypotension. METHODS: Adult patients undergoing surgery under general anesthesia were enrolled after excluding patients with cardiovascular disease or ASA-PS ≥ III. Ultrasonographic IJV images were recorded in both the supine and 10° Trendelenburg positions immediately before induction. Using these images, IJV area (IJV-A), diameter and change rate with posture were measured. Hypotension during induction was defined as mean BP < 60 mmHg or > 30% decrease from baseline. RESULTS: Hypotension during induction was observed in 37 of 82 patients. IJV-A in the Trendelenburg position was 2.02 ± 0.86 and 1.72 ± 0.68 in the hypotensive and non-hypotensive groups, respectively (P = 0.08). Logistic regression analysis performed using age, use of calcium antagonists, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, baseline mean BP and IJV-A in the Trendelenburg position as variables showed that IJV-A in the Trendelenburg position was an independent predictor of hypotension, with an adjusted odds ratio of 3.11 (95% CI 1.07-9.03, P = 0.04). Area under the curve was 0.595 (95% CI 0.469-0.722) for IJV-A in the Trendelenburg position. CONCLUSION: IJV-A in the Trendelenburg position was an independent predictor of hypotension during induction. Further study is required to examine the diagnostic accuracy of IJV-A as a predictor for hypotension during induction.

DOI： 10.1007/s00540-019-02675-9

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A 12-year-old male patient with Coffin-Lowry syndrome was scheduled for posterior cervical decompression and fusion for cervical spinal injuries. The patient had features of Coffin-Lowry syndrome including mental retardation, prominent forehead, a short nose with a wide tip, a wide mouth with full lips, short stature, microcephaly, and kyphoscoliosis. We anticipated major troubles related to anesthesia such as difficult ventilation and intubation, communication difficulty during induction and extubation, and difficulty in using a naso-pharyngeal airway. In addition, we had to stabilize neck alignments during intubation because cervical vertebrae were unstable and spinal cord has already been injured. Therefore, we scheduled slow induction with sevoflurane maintaining spontaneous respiration. As we found the full mouth opening of the patient after the induction, we inserted an intubating laryngeal mask, through which ventilation was successfully maintained. A tracheal tube was inserted through the intubating laryngeal mask. When the surgery was completed, we extubated using a tube introducer in the trachea. As we found that the patient's airway was open, we removed the introducer. In conclusion, with a thorough planning of the anesthetic management we successfully managed anesthesia for cervical spinal surgery in a patient with Coffin-Lowry syndrome.

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Transesophageal echocardiography (TEE) is a useful tool for assessment of cardiac function in patients undergoing cardiac surgery or in patients undergoing non-cardiac surgery who have cardiovascular complications. Left ventricular (LV) function is composed of systolic function, diastolic function, preload and afterload. To assess systolic and diastolic function several methods are used, and we must use them based on the property of each parameter. Both systolic and diastolic functions are load dependent. To assess the systolic function, ejection fraction (EF) is commonly used. Transmitral flow (TMF) and pulmonary vein flow patterns are commonly used to assess the diastolic function. Newer techniques including mitral annular velocity and color M-mode TMF propagation velocity (Vp) may be less sensitive to changes in loading conditions. LV dP/dt is not affected by preload, and myocardial performance index (Tei index) can be used to assess both systolic and diastolic functions. Tei index is also useful to assess right ventricular function. The recently developed real time 3-dimensional system provides accurate and objective information, such as LV volumetry, wall motion, dyssyncrony and valvular pathology.

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BACKGROUND: Plasma levels of D-dimer, soluble fibrin monomer complex (SFMC) and FDP were measured in 40 patients for orthopedic lower extremity surgery, using a recently established monoclonal antibody to clarify if these markers are good indicator of deep vein thrombosis(DVT). METHODS: Subjects were 20 patients for total hip arthroplasty (THA) or total knee arthroplasty (TKA) (group A) and 20 patients for hip fracture surgery (group F). D-dimer, SFMC and FDP were measured at induction of anesthesia. RESULTS: Preoperative values of D-dimer, FMC and FDP in group F were higher than those in group A, and these values in group F were higher than normal values. CONCLUSIONS: It is concluded that plasma levels of D-dimer, SFMC and FDP in the patients with hip fracture were higher than those in the patients scheduled for TKA or THA in perioperative period. These suggest that the patients with hip fracture have high risk of DVT.

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BACKGROUND: Gum elastic bougie (GEB) is one of the most useful devices for patients whose tracheas are difficult to intubate during anesthetic induction. But no previous study has evaluated the effects of the types of the tracheal tube. We hypothesized that wire-reinforced tracheal tubes were superior to standard tracheal tubes in the success rate of tracheal intubation when using GEB. We compared these two different types of tracheal tubes in using GEB. METHODS: Forty patients were subjected and randomly allocated into two groups; patients intubated with standard tracheal tubes (Group , n = 20) and those with wire-reinforced tracheal tubes (Group S, n = 20). Measured variables were intubation time defined as elapsed time from mouth opening to removal of GEB from tracheal tube, heart rate (HR), and systolic blood pressure(SBP). We also compared trial times of intubation and pharyngeal or laryngeal bleeding as a minor side effect. RESULTS: Trachea was successfully intubated in the frist attempt in 37 patients (92.5%), and the rest of the patients were all intubated at second trial. Intubation times of Group P and Group S were 41.5 +/- 13.9s and 41.3 +/- 11.1s, respectively. There were no significant differences in HR and SBP between the groups. CONCLUSIONS: The type of tracheal tube would not affect the success rate and time of intubation when using gum elastic bougie.

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BACKGROUND: Plasma levels of D-dimer, fibrin monomer complex (FMC) and FDP were measured in 10 patients who underwent hip fracture surgery, using a recently established monoclonal antibody to clarify if these markers are good indicators of deep vein thrombosis (DVT). METHODS: Subjects were 10 (4 male and 6 female) hip fracture patients, aged 87 +/- 6 years. D-dimer, FMC and FDP were measured at induction of anesthesia and 24 hours as well as 6 days after operation. RESULTS: Preoperative values of D-dimer, FMC and FDP were higher than normal values, and these markers remained high during the postoperative period. CONCLUSIONS: It is concluded that plasma levels of D-dimer, FMC and FDP in the patients with hip fracture were high in perioperative period. Among these markers, FMC was the most useful indicator for the diagnosis at the early stage of DVT.

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BACKGROUND: A large number of studies have examined the incidence of thromboembolic complications after orthopedic surgery of the lower extremity. We investigated the perioperative changes of coagulability following total knee arthroplasty (TKA) or total hip arthroplasty (THA) using thromboelastography (TEG), which could comprehensively assess the coagulation and fibrinolytic system. METHODS: Thirty patients scheduled for TKA (n= 10), THA (n= 10) and other lower extremity orthopedic surgery (control, n= 10) were studied. TEG was analyzed with K-value, MA-value and coagulation index (CI) before induction of anesthesia and 24 hours after surgery. RESULTS: K-values decreased significantly after TKA and THA compared with the values before the induction of anesthesia. MA-values and CI increased significantly after TKA and THA compared with the values before the induction. There were no significant changes in K-value, MA-value and CI in the control group during the perioperative period. CONCLUSIONS: The results suggest that TKA and THA lead blood coagulation to hypercoagulable state at the early postoperative stage.

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We experienced a case of spontaneous intracranial hypotension (SIH) complicated with depressed consciousness after its treatment. A 56-year-old woman developed postural headache, and her MRI revealed bilateral chronic subdural hematoma (CSH). After treatment with epidural autolongous blood patch, her headache resolved completely. However, two days after, the patient developed depressed conciousness, and MRI showed brain sagging and downward brain displacement. After management with conservative treatment, including second epidural blood patch and hematoma drainage, the patient became alert and other symptoms resolved gradually. We demonstrated that caution should be taken for the management of SIH, especially in the case associated with CSH.

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BACKGROUND: The effect of anesthetics on somatosensory evoked potential (SEP) and auditory brain stem response (ABR) has been a subject of intense reseach over the last two decades. In fact, volatile anesthetics have been repeatedly shown to decrease cortical amplitude in a dose-dependent fashion but the information regarding the effect of propofol is incomplete. The purpose of this study was to compare the effects of sevoflurane and propofol on evoked potentials during comparable depth of anesthesia guided by bispectral index (BIS). METHODS: Forty four patients scheduled for neurosurgery were studied. Anesthesia was maintained with intravenous propofol using target controlled infusion (TCI). We measured the change of amplitude and latency of SEP(N20-P25), ABR (V wave) and visual evoked potential (VEP: P100) at three sets of sevoflurane (0%, 1%, 2%) or propofol concentrations (effect site concentration of 1.5, 2.0, 3.0 microug x ml(-1)). BIS monitor was used to measure relative depth of hypnosis. RESULTS: With increasing concentrations of sevoflurane (0, 1% and 2%), SEP showed dose-related reduction in its amplitude, ABR produced less marked changes and VEP showed a significant reduction at 1%. VEP at the propofol concentration of 3.0 microg x ml(-1) was decreased significantly compared with the amplitude at 1.5 microg x ml(-1) concentration. No significant change was observed with SEP and ABR during the change of propofol dosages. BIS values were almost the same with each anesthetics. CONCLUSIONS: VEP was most strongly affected with anesthetics, and ABR showed less marked influence of sevoflurane and propofol. Propofol based TIVA technique would induce less change in evoked potentials than sevoflurane.

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BACKGROUND: Previous studies suggest that normothermic cardiopulmonary bypass(CPB) impairs cerebral oxygen balance. We studied the effect of normothermic CPB on cerebral oxygen balance evaluated by continuous measurement of oxygen saturation in the jugular vein (SjO2). METHODS: Eleven patients undergoing coronary artery bypass grafting with normothermic CPB were studied. A 4 Fr oxymetry catheter was inserted into the internal jugular bulb for SjO2 monitoring. We measured mean arterial pressure (MAP), SjO2 and hemoglobin (Hgb) concentration at five time points-1) pre CPB, 2) 3) 4) 5, 30, 60 min after the onset of CPB, respectively, 5) 5 min after the end of CPB. RESULTS: MAP decreased significantly 30 min (47 +/- 9 mmHg) and 60 min (48 +/- 9 mmHg) after the onset of CPB compared with the pre CPB (80 +/- 14 mmHg) value. Hgb also decreased significantly 5 min (7.8 +/- 1.1 g x dl(-1)) and 30 min (7.1 +/- 1.0 g x dl(-1)) and 60 min (7.1 +/- 0.8 g x dl(-1)) after the onset of CPB compared with the pre CPB (11 +/- 1.0 g x dl(-1)) value. However, SjO2 showed no significant change throughout the study period. No significant correlation was observed between MAP and SjO2. CONCLUSIONS: Cerebral oxygen balance assessed by SjO2 was not impaired during normothermic CPB, and was unaffected by hypotension and hemodilution.

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BACKGROUND: Serious side effects of postoperative analgesia with opioid drugs include nausea and vomiting. METHODS: We investigated the effects of various factors (patient background, anesthesia duration, and intraoperative drug use) on the frequency and degree of postoperative nausea and vomiting (PONV) during the first 24 hours of intravenous patient-controlled analgesia (PCA) with fentanyl. RESULTS: PONV occurred in 34% of the male patients and 68% of the female, and in 31% and 58% of smokers and non-smokers, respectively. CONCLUSIONS: Consideration should be given to gender and smoking status prior to starting preventive antiemetic therapy using PCA with fentanyl following cervical spine surgery.

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