Unexpected Complication of R-CHOP Chemotherapy: Rapidly Progressive Bronchiolitis Obliterans Syndrome

Background: Bronchiolitis obliterans syndrome (BOS) is the term used for the progressive obliteration of small airways before the patient has had a confirmatory lung biopsy. It is also recognized as a transplant-related complication. There have been no reports of BOS during initial standard chemotherapy. Case presentation: A 50-year-old woman with newly diagnosed follicular lymphoma grade 2, stage 3A, presented with hypoxia and progressive dyspnoea after the fifth cycle of R-CHOP. High-resolution computed tomography showed air trapping enhanced at the end-expiratory phase. Pulmonary function testing revealed severe obstructive and restrictive failure without bronchodilator response. We diagnosed BOS based on current criteria and treated the patient with glucocorticoids and cyclosporin. She was discharged home on oxygen therapy. However, soon after discharge, her respiratory symptoms deteriorated and she was hospitalized in a palliative care unit. She died of respiratory failure within a year of symptom onset. Conclusions: This is the first case report to describe rapidly progressive BOS in a patient undergoing R-CHOP treatment, which strongly suggests the condition was caused by the chemotherapy. Although a pathological diagnosis was not obtained, the clinical diagnosis of BOS was important so that the patient could receive appropriate treatment and palliative care based on the prognosis of this incurable condition

Effects of Neostigmine and Sugammadex on QT Interval and QT Dispersion

Dispersion of QT dispersion(QTD)in 12-lead electrocardiogram is a useful index for assessment of ventricular arrhythmia risk and cardiovascular event. To determine the effects of reversal of nondepolarizing neuromuscular blockade on cardiovascular event, we evaluated the QT interval QTD after reversal of the neuromuscular blockade by neostigmine or sugammadex.After obtaining the approval of the ethics committee of Dokkyo Medical University Hospital, 40 patients with ASA physical status I or II were allocated to following two groups. Patients in the groups N(n=16)and S(n=15)received combination of neostigmine(40?μg/kg)and atropine(20?μg/kg)or sugammadex(2?mg/kg)as a reversal of neuromuscular blockade after the operation under 1% sevoflurane anesthesia, respectively. The RR interval, QT interval(QT), corrected QT interval(QTc), QT dispersion and corrected QT dispersion(QTcD)were consecutively recorded using computerized measurement before and after administration of reversal agents in both groups.RR interval in the group N significantly decreased 1-4?min after reversal of the neuromuscular blockade, but not in the group S. However, in the groups N and S, QT interval, QTc interval, QTD and QTcD were not changed after reversal of the neuromuscular blockade. Moreover, there was no significant difference between both groups in QT interval, QTc interval, QTD and QTcD during the study.Our results suggest that neither neostigmine nor sugammadex may increase the risk of ventricular arrhythmia and cardiovascular events in reversal of the neuromuscular blockade under sevoflurane anesthesia

Low Dose Landiolol Combined with Catecholamine Can Decrease Heart Rate without Suppression of Cardiac Contraction after Cardiopulmonary Bypass

Objective:Landiolol is a new ultra-short acting beta-adrenergic blocker that has potential for use in perioperative hemodynamic stabilization. The purpose of this study was to examine the effect of combined administration of landiolol and Catecholamine on regulation of heart rate in tachycardia after cardiopulmonary bypass.Design:The study was performed as a prospective controlled trial. Setting:A university hospital.Participants:The subjects were 30 of 64 patients with heart rate ≧ 115 bpm after weaning from cardiopulmonary bypass.Interventions:Fifteen of the patients (the landiolol group) were administered landiolol at a dose of 3-5 mg/kg/min without a decrease in the dose of Catecholamine. The other 15 patients( the control group)did not receive landiolol, but the Catecholamine dose of 1 m g/kg/min was decreased to reduce the heart rate.Results:Mean arterial pressure, cardiac index and heart rate were measured 5, 10 and 15 min after drug administration and postoperatively. Mean arterial pressure and cardiac index were unchanged after drug administration, but heart rate was significantly lower after 15 min and postoperatively in patients administered landiolol compared with those who did not receive landiolol. Conclusions:Combined administration of landiolol and Catecholamine is useful for stabilization of cardiovascular changes after cardiopulmonary bypass surgery

ロボット支援下前立腺全摘除術の麻酔管理：600例の経験から

ロボット支援下前立腺全摘除術（RARP）は恥骨後式前立腺全摘除術に比べ低侵襲で，当施設でも一般的な手術となり，既に700例近いRARPの麻酔管理を経験してきた．RARPを当施設で開始するにあたっては，泌尿器科医と手術室看護師，臨床工学士と共に，必要な情報収集と様々な準備を行い，幾度とシミュレーションを実施してきた結果，これまでに深刻な合併症を経験していない．しかしながら，RARPでは，良好な術野確保のため，高度な頭低位，気腹などの特殊な状況に患者が曝されるため，麻酔管理中は最新の注意を払う必要がある．RARPの安全性を確保するために，今後も経験を重ねて，RARPの麻酔管理の質を向上し行かなければならない．Robot associated radical prostatectomy（RARP）is less invasive than open radical retropubic prostatectomy. RARP has become popular in our facility. We have already experienced near 700 cases about anesthetic management of RARP. Before starting RARP in our facility, we have obtained many required knowledges, prepared many things and done its simulations together with urologists, nurses and clinical engineers. Fortunately, until now, we have never experienced serious problems during its peri-operative management. To obtain superior surgical field during RARP, there are many special situations, such as head-down tilt and pneumoperitoneum, to patients. So that, we should pay careful attention about anesthetic management of RARP and further improve anesthetic management of RARP to increase safety based on our experiences

Comparison of 0.2% Ropivacaine and 0.25% Bupivacaine in Pediatric Caudal Block : Evaluation of Postoperative Pain and Plasma Concentration of Local Anesthetics

The purpose of this study is to assess the effects of pediatric caudal block using 0.2% ropivacaine or 0.25% bupivacaine on intraoperative and postoperative analgesia. We also examined plasma concentrations of the local anesthetics after caudal injection. Forty children, who were scheduled for inguinal herniorrhaphy, underwent caudal block with 0.2% ropivacaine 1 ml/kg (group R, n=20) or 0.25% bupivacaine 1 ml/kg (group B, n=20) after induction of general anesthesia. Anesthesia was maintained using a face mask with 66% nitrous oxide in oxygen supplemented with sevoflurane. Postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured using gas chromatography. Since two patients in Group R and one patient in Group B required more than 1 % of sevoflurane to prevent their body movement when the surgical procedure was started, they were excluded from this study as the failed block. No patient in Groups R and B required intraoperative analgesics under light general anesthesia and postoperative analgesics. The maximum plasma concentration of ropivacaine and bupivacaine were 0.70±0.28μg/ml at 45 min and 0.80±0.42μg/ml at 30 min after the caudal injection, respectively. In conclusion, pediatric caudal block with 0.2 % ropivacaine is an alternative to 0.25 % bupivacaine for intraoperative and postoperative analgesia

Block of the Ganglion Impar for Treatment of a Patieat with Non-malignant Chronic Perineal Pain

A 62 year-old woman with chronic perineal pain was successfully managed by chemical neurolysis. When she was referred to us, other practitioners had already investigated her. However, the cause of pain was not identified and the pain was refractory to conventional analgesic treatment. She underwent caudal block with 0.25% bupivacaine 5 ml six times to avoid placebo response of the block prior to therapeutic neurolysis. Then, block of the ganglion impar with phenol water under fluoroscopy was performed. Six months later, she still has no pain

Differences In Duration and Magnitude of Vasodilative Effect by Sympathetic Block with Ropivacaine 0.2 % and Mepivacaine 0.5 % in Dogs

To clarify differences in the duration and magnitude of vasodilative effect induced by sympathetic block with ropivacaine and mepivacaine. We measured mean arterial pressure (MAP), heart rate (HR), and right and left brachial artery blood flow (BABF) before and after stellate ganglion block (SGB) used as sympathetic block in twelve dogs. The experimental protocol was designed as follows : (1) left SGB using 0.2% ropivacaine 1.0 mL (n=6) and left SGB using 0.5 % mepivacaine 1 mL (n=6). MAP and HR did not change significantly through-out the study in either group. Left SGB with ropivacaine increased left BABF significantly from 5 min through 80 min after SGB (baseline, 100% ; peak at 10 min after SGB, 257±39% ; P<0.01). Left SGB with mepivacaine increased left BABF significantly from 5 min through 50 min after SGB (baseline, 100% ; peak at 10 min after SGB, 183±31% ; P<0.01). The values of left BABF after SGB with ropivacaine were significantly higher than those of SGB with mepivacaine from 5 min through 80 min after the block. Right BABF after left SGB decreased in both groups. Sympathetic block with 0.2% ropivacaine induces significant increases in both duration and magnitude of action in the peripheral blood flow compared with that of 0.5% mepivacaine