吉永 晃一

Intravenous leiomyomatosis (IVL) with intracardiac extension can cause circulatory collapse during anesthetic induction due to right heart obstruction. We report the case of a 63-year-old woman with IVL extending into the right ventricle, presenting with right heart failure and shock. To maintain hemodynamic stability and facilitate tumor resection, we established cardiopulmonary bypass (CPB) under local anesthesia before inducing general anesthesia. Preoperative imaging revealed a tumor extending from the right ovarian vein to the right ventricle, causing circulatory failure. In the operating room, CPB was initiated via femoral cannulation under local anesthesia with analgosedation to maintain spontaneous breathing, followed by general anesthesia induction. A median sternotomy was performed, and an additional venous cannula was placed in the superior vena cava to achieve total CPB. The tumor was resected from the right heart and inferior vena cava. The patient was weaned from CPB and ventilation without complications. Pathology was later confirmed to be IVL. She was discharged on postoperative day 30. Establishing CPB before anesthetic induction maintained hemodynamic stability in this patient with IVL, intracardiac extension, and right heart failure, allowing for safe tumor resection.

BACKGROUND: Intercostal nerve block (ICNB) plus intravenous (IV) patient-controlled analgesia (PCA) could be an alternative method of perioperative pain management in patients undergoing video-assisted thoracic surgery (VATS). However, the efficacy of this strategy has not been established. METHODS: A retrospective observational study was conducted at an acute care hospital in Japan. Among patients who underwent VATS under general anesthesia from January 1, 2012, to December 31, 2022, we included those who received ICNB or thoracic epidural anesthesia (TEA). The ICNB group had postoperative IV PCA, and the TEA group had postoperative epidural PCA. VATS indicated for pneumothorax or biopsy was excluded. The primary outcome was the maximum pain score measured by the numerical rating scale on postoperative day 1. Secondary outcomes included the times rescue analgesics were used and the use of antiemetics. Propensity score matching was performed to minimize bias from nonrandomized assignment of anesthesia methods. RESULTS: Among 1,641 patients who met the criteria, 590 underwent ICNB and IV PCA, while 1,051 received TEA. After 1:1 propensity score-matching, 456 were in each group. The median (interquartile range) pain score on postoperative day 1 was higher in the ICNB group than in the TEA group, with values of 5 (4-7) vs. 3 (2-5) (p < 0.0001). Patients in the ICNB group more frequently used rescue analgesics on postoperative day 0, with values of 2 (1-2) vs. 1 (1-2) (p < 0.0001), and had a higher proportion of receiving antiemetics on postoperative day 1 (13.4% vs. 6.1%, p = 0.0004), compared to the patients in the TEA group. CONCLUSIONS: ICNB plus IV PCA was inferior to TEA for postoperative pain management of VATS in the study population. Protocol-based prospective studies are needed to determine the efficacy of this strategy.

BACKGROUND: Patients with end-stage renal disease on hemodialysis (HD) undergoing cardiac surgery face increased risks. Mixed venous saturation (SvO2) is an important parameter representing the systemic oxygen supply-demand balance. However, interpreting SvO2 in HD patients may be challenging due to arteriovenous fistulas. The literature on these issues is lacking. This study aimed to investigate the change in SvO2 in HD patients by comparing those in non-HD patients perioperatively. METHODOLOGY: From April 1, 2019, to March 31, 2020, 39 patients undergoing cardiac surgery with pulmonary artery catheters, 18 with and 21 without HD, were identified. The cardiac index (CI) and SvO2 were extracted from patient records, and the oxygen delivery index (DO2I) was calculated before surgery (T0), on intensive care unit (ICU) admission (T1), 24 hours (T2), and 48 hours (T3) after ICU admission. A linear mixed effects model was applied for repeated measures analyses. RESULTS: T0 CI was significantly higher in the HD group (2.5 ± 0.5 vs. 2.0 ± 0.5 L/minute/m2, mean ± SD, P = 0.003) and increased significantly over time in both groups, without an interaction effect (P for interaction = 0.12). T0 SvO2 did not differ between groups (72 ± 10% vs. 72 ± 5%, P = 0.97) and decreased over time, more evidently in the non-HD group (P for interaction = 0.016). DO2I was similar in both groups perioperatively. CONCLUSIONS: SvO2 tended to be higher in the HD group perioperatively. If SvO2 in HD patients is similar to that in non-HD patients, this may mean that the oxygen supply-demand balance is disturbed.