This research aims to investigate the impact of fever on total mechanical ventilation time (TVT) in critically ill patients. Subgroup analysis was conducted using a previous prospective, multicenter observational study. We included mechanically ventilated patients for more than 24 hours from 10 Korean and 15 Japanese intensive care units (ICU), and recorded maximal body temperature under the support of mechanical ventilation (MAX(MV)). To assess the independent association of MAX(MV) with TVT, we used propensity-matched analysis in a total of 769 survived patients with medical or surgical admission, separately. Together with multiple linear regression analysis to evaluate the association between the severity of fever and TVT, the effect of MAX(MV) on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAX(MV) ≥ 37.5°C was significantly associated with longer mean TVT by 5.4 days in medical admission, and by 1.2 days in surgical admission, compared to those with MAX(MV) of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAX(MV) of 37.5°C to 38.4°C, 38.5°C to 39.4°C, and ≥ 39.5°C) sustained a significantly longer duration of TVT than those with normal range of MAX(MV) in both categories of ICU admission. A significant association between MAX(MV) and mechanical ventilator-free days was also observed in all enrolled subjects. Fever may be a detrimental factor to prolong TVT in mechanically ventilated patients. These findings suggest that fever in mechanically ventilated patients might be associated with worse mechanical ventilation outcome.
The surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response.
Abstract Background Spontaneous retroperitoneal hematoma is defined as bleeding in the retroperitoneal space without any triggers such as trauma, invasive procedures, and abdominal aortic aneurysm. Case presentation A 48-year-old Japanese man who experienced sudden abdominal pain, severe hypotension, and decreased hemoglobin was diagnosed with spontaneous retroperitoneal hematoma. Contrast-enhanced computed tomography revealed massive left retroperitoneal hematoma; however, neither extravasation nor causative aneurysm was noted. Through conservative management with close monitoring, he was treated and discharged on the tenth hospital day without any morbidity. Conclusions Spontaneous retroperitoneal hematoma treatment comprises conservative management, transcatheter arterial embolization, and surgical intervention. The mortality rate of spontaneous retroperitoneal hematoma is so high that the optimal treatment timing needs to be carefully judged on the basis of detailed evaluation, and management algorithm with clear criteria.
A 74-year-old woman underwent radical nephrectomy for an adrenaline predominant pheochromocytoma in the left adrenal gland. She was pretreated with doxazosin for 3 weeks before surgery. Anesthesia was induced with intravenous fentanyl, midazolam and vecuronium, and inhaled sevoflurane in oxygen. A central venous catheter was inserted into the right internal jugular vein and a PiCCO catheter was inserted into the femoral artery for the monitoring of cardiac function and hemodynamics. In addition, continuous monitoring and automatic control of blood glucose were started using STG-22. Target concentration of blood glucose was set at 120-140 mg x dl(-1). Anesthesia was maintained with sevoflurane and remifentanil. Prostaglandin E1, nitroglycerin and dexmedetomidine were infused continuously from the start of surgery, and the systolic blood pressure was kept within 120-160 mmHg. During surgical manipulation around the tumor, there were sudden increases in blood pressure, heart rate and blood glucose concentration. Thus, phentolamine and landiolol were also administered to control blood pressure and heart rate. On the contrary, after the tumor removal, noradrenaline, dobutamine and milrinone were required to maintain blood pressure. The STG-22 worked well to maintain blood glucose concentrations during surgery without any hyper- and hypoglycemic events.
Laryngeal granuloma development can be a postoperative complication of laryngeal trauma or irritation resulting from general anesthesia and endotracheal intubation. These rare benign lesions are located primarily over the cartilaginous portions of the larynx, particularly the vocal processes of the arytenoids. Airway manipulation during the intubation process and prolonged intubation periods can be contributing factors to intubation-related laryngeal granulomas, which may manifest 1 to 4 months after intubation. The patient in this case was a female who returned with complaints of throat pain without hoarseness or sensations of a "lump in her throat" 3 months following surgery, during which she was intubated with a 7.0-mm nasotracheal tube for 30 hours, likely contributing to her bilateral laryngeal granulomas. The patient underwent successful conservative medical management consisting of a proton pump inhibitor and an inhaled corticosteroid.
We gave anesthesia for craniotomy in a 54-year-old man with intracranial tumor near the Broca speech centers causing facial nerve palsy and slight allophasis. Nasotracheal intubation was performed after intravenous administration of droperidol 15 mg and fentanyl 0.2 mg. The head was fix with 3 pins with the patient in the right lateral position, and endotracheal tube was withdrawn to the pharynx confirming the speech of the patient. The patient was intubated again using fiberscope after intravenous midazolam 3 mg with inhalation of nitrous oxide. Nitrous oxide was discontinued for 2 hours after the start of surgery for the speech mapping, and the patient emerged from anesthesia in 5 minutes. He pronounced the letters on cards during the speech mapping. After the successful mapping, the patient was intubated again using fiberscope after administration of fentanyl 0.1 mg. Anesthesia was maintained again with nitrous oxide. The patient recovered from anesthesia quickly after surgery without any events. On the post-operative round, the patient could not remember well the anesthetic induction and the awakening during the brain mapping. Three episodes of intubation caused no complications, and the neurological symptoms disappeared in several days.
In Response: We thank Dr. Neustein for telling us about the Neustein Laryngoscope (1). We were not aware of his laryngeal mirror (2,3) when we submitted our letter (4). We agree that Dr. Neustein created a fine laryngeal mirror to help visualize the vocal cord in cases with difficult intubation. However, the device is not readily available. The dental mirror is a popular device that is readily available. The dental mirror is readily available and a useful option in cases of difficult intubation. Takeshi Yokoyama, DDS, PhD Koichi Yamashita, MD, PhD Masanobu Manabe, MD, PhD Department of Anesthesiology and Critical Care Medicine Kochi Medical School Nankoku, Japan [email protected]
In summary, an incremental dosage of aspirin (660 mg) shortens the bleeding time prolonged by daily low-dosage aspirin (81 mg) in healthy subjects. The "Aspirin Reversal" phenomenon might be useful to control excessive bleeding during surgery in patients taking daily low-dosage aspirin as anti-coagulants.
