末盛 智彦

We compared the reintubation rate in children who received high-flow nasal cannula (HFNC) therapy to the rate in children who received noninvasive ventilation (NIV) therapy for acute respiratory failure (ARF) after cardiac surgery. This was a retrospective analysis of 35 children who received HFNC therapy for ARF after cardiac surgery in 2014-2015 (the HFNC group). We selected 35 children who had received NIV therapy for ARF after cardiac surgery in 2009-2012 as a control group. The matching parameters were body weight and risk adjustment for congenital heart surgery category 1. The reintubation rate within 48 h in the HFNC group tended to be lower than that in the NIV group (3% vs. 17%, p=0.06). The reintubation rate within 28 days was significantly lower in the HFNC group compared to the NIV group (3% vs. 26%, p=0.04). The HFNC group's ICU stays were significantly shorter than those of the NIV group: 10 (IQR: 7-17) days vs. 17 (11-32) days, p=0.009. HFNC therapy might be associated with a reduced reintubation rate in children with ARF after cardiac surgery.

OBJECTIVE: There has been controversy regarding the beneficial effects of calcium on myocardial contractility and the harmful effects on myocardial cells, especially in children. The aim of this study was to investigate an association between ionized calcium concentration (iCa) and outcomes for pediatric patients after cardiac surgery. DESIGN: A retrospective, single-center study from May 2013 to December 2014. SETTING: Referral high-volume pediatric cardiac center in a tertiary teaching hospital. PATIENTS: Patients <72 months old with congenital heart disease who underwent palliative or definitive surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between pH-corrected iCa within 24 hours after surgery and intensive care unit (ICU) length of stay (ILOS) was defined as the primary outcome. The highest iCa (iCamax), lowest iCa (iCamin), and time-weighted average iCa (iCaave) were stratified and compared with the outcomes. The authors reviewed 5,468 ionized calcium measurements from 357 consecutive pediatric patients during the study period. One patient died at postoperative day 34 in the ICU. Significant differences in ILOS were observed among patients after cardiopulmonary bypass (CPB) according to iCaave, iCamax, and iCamin but not among patients without CPB. Patients with CPB and an iCaave value of 1.31-to-1.40 mmol/L, 1.41-to-1.50 mmol/L, 1.51-to-1.60 mmol/L, and >1.60 mmol/L stayed in the ICU for 7 (interquartile range [IQR] 4-10) days, 8 (IQR 6-16) days, 10 (IQR 8-14) days, and 19 (IQR 12-38) days, respectively, which was significantly longer than the ILOS of 5 (4-8) days for patients with an iCaave of 1.21-to-1.30 mmol/L. Even after adjustment for other predictors of ILOS using multivariable analyses, there were significant relationships of ILOS with iCaave and iCamin values of >1.50 mmol/L among patients with CPB. CONCLUSIONS: Higher iCa within 24 hours after congenital cardiac surgery using CPB was independently associated with longer LOS in the ICU.

We will investigate the incidence of postoperative pulmonary complications (PPCs) with the prophylactic use of a high-flow nasal cannula (HFNC) after pediatric cardiac surgery. Children < 48 months old with congenital heart disease for whom cardiac surgery is planned will be included. The HFNC procedure will be commenced just after extubation, at a flow rate of 2 L/kg/min with adequate oxygen concentration to achieve target oxygen saturation ≥ 94%. This study will reveal the prevalence of PPCs after pediatric cardiac surgery with the prophylactic use of HFNC.

Although near-infrared spectroscopy (NIRS) enables bedside assessment of cerebral oxygenation, it provides little information on the cause of deoxygenation. The authors aimed to investigate the changes in cerebral oxygenation and haemoglobin concentration and their associations during paediatric cardiac surgery in order to elucidate the physiology underlying cerebral deoxygenation. An observational retrospective study on 399 patients who underwent paediatric cardiac surgery was conducted. With use of NIRS, cerebral oxygen saturation as expressed by tissue oxygen index (TOI) before and after surgery, concentration changes in oxygenated haemoglobin (Δ[HbO2]) and deoxygenated haemoglobin (Δ[HHb]) after surgery were studied as were the associations between these values and clinical variables. TOI decreased after surgery (preoperative versus postoperative value, 66.0% [56.9, 71.3] versus 63.2% [54.3, 69.4], median [25th, 75th percentile], P <0.001) and the decrease was greater in higher category groups in the Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1). [HHb] increased from its baseline (+1.74 μmol/l [-1.57, +5.84], P <0.001) and the increase was greater in higher risk category groups. On the contrary, there was no evidence for a change in [HbO2] (+0.45 μmol/l [-4.76, +5.30], P=0.42). Cerebral oxygen saturation decreased after paediatric cardiac surgery and the decrease was greater in patients of higher risk groups. The increase in [HHb] was considered to play a predominant role in the cerebral deoxygenation noted, in particular in higher RACHS-1 category groups.

BACKGROUND: Reintubation after pediatric cardiac surgery is associated with a high rate of mortality. Therefore, adequate respiratory support for postextubation acute respiratory failure (ARF) is important. However, little is known about the physiological impact of high-flow nasal cannula (HFNC) therapy on ARF after pediatric cardiac surgery. Our working hypothesis was that HFNC therapy for postextubation ARF after pediatric cardiac surgery improves hemodynamic and respiratory parameters. METHODS: This was a prospective observational study conducted at a single university hospital. Children less than 48 months of age who had postextubation ARF after cardiac surgery were included in this study. HFNC therapy was started immediately after diagnosis of postextubation ARF. Data obtained just before starting HFNC therapy were used for pre-HFNC analysis, and data obtained 1 h after starting HFNC therapy were used for post-HFNC analysis. We compared hemodynamic and respiratory parameters between pre-HFNC and post-HFNC periods. The Wilcoxon signed-rank test was used to analyze these indices. RESULTS: Twenty children were included in this study. The median age and body weight were 4.5 (2.3-14.0) months and 4.3 (3.1-7.1) kg, respectively. Respiratory rate (RR) significantly decreased from 43.5 (32.0-54.8) to 28.5 (21.0-40.5) breaths per minute (p = 0.0008) 1 h after the start of HFNC therapy. Systolic blood pressure also decreased from 87.5 (77.8-103.5) to 76.0 (70.3-85.0) mmHg (p = 0.003). Oxygen saturation, partial pressure of arterial carbon dioxide, heart rate, and lactate showed no remarkable changes. There was no adverse event caused by HFNC therapy. CONCLUSIONS: HFNC therapy improves the RR of patients who have postextubation ARF after pediatric cardiac surgery without any adverse events.

75歳女性。第3・4腰椎レベルの硬膜内髄外腫瘍に対し腫瘍摘出術が予定された。レミフェンタニル、プロポフォールによる麻酔管理を行い、術中の血圧変動にはフェニレフリン、ニカルジピンを使用し、手術は終了した。麻酔終了後の覚醒遅延を契機に頭蓋内出血、気脳症を発症したが、対症療法を主体とした全身管理を行ったところ、術後1日目のCTで気脳症や頭蓋内出血の改善が確認された。その後、徐々に意識レベルは改善し、軽度の認知機能障害が残存したものの、術後22日目に転院となった。

BACKGROUND: Near-infrared spectroscopy (NIRS) provides an assessment of cerebral oxygenation and tissue hemoglobin concentration. AIM: The aim of this study was to investigate whether the cerebral oxygenation and hemoglobin concentration measured with NIRS could predict outcomes after pediatric cardiac surgery. METHOD: We conducted a retrospective observational study in 399 patients who underwent pediatric cardiac surgery. Associations were determined between postoperative outcome and preoperative and postoperative cerebral tissue oxygenation index (TOI), postoperative normalized tissue hemoglobin index (nTHI), concentration changes in oxygenated hemoglobin (Δ[HbO2 ]) and deoxygenated hemoglobin (Δ[HHb]). RESULTS: Thirty-nine children had major postoperative morbidity and 12 died. Using Spearman's correlation analysis, postoperative lower TOI and higher Δ[HHb] were associated with longer stays in the Intensive Care Unit (ICU) (r = -0.48, P < 0.001, r = 0.31, P < 0.001, respectively) and longer duration of intubation (r = -0.48, P < 0.001, r = 0.31, P < 0.001, respectively) and higher probability of death determined by the Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1) (r = -0.39, P < 0.001, r = 0.23, P < 0.001, respectively). In multivariate regression analysis, postoperative TOI was independently associated with major morbidity and mortality and Δ[HHb] was independently associated with major morbidity. In receiver operating characteristic analysis, postoperative TOI and Δ[HHb] predicted major morbidity (Area under the curve [AUC] = 0.72, 0.68, respectively) and mortality (AUC = 0.81, 0.69, respectively). CONCLUSION: Lower TOI or higher [HHb] at the end of surgery and higher RACHS-1 category predicted worse outcomes.

PURPOSE: The benefit of tranexamic acid (TXA) in pediatric cardiac surgery on postoperative bleeding has varied among studies. It is also unclear whether the effects of TXA differ between cyanotic patients and acyanotic patients. The aim of this study was to test the benefit of TXA in pediatric cardiac surgery in a well-balanced study population of cyanotic and acyanotic patients. METHODS: A total of 160 pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (81 cyanotic, 79 acyanotic) were included in this single-blinded, randomized trial at a tertiary care university-affiliated teaching hospital. Eighty-one children (41 cyanotic, 40 acyanotic) were randomly assigned to a TXA group, in which they received 50 mg/kg of TXA as a bolus followed by 15 mg/kg/h infusion and another 50 mg/kg into the bypass circuit. The other 79 patients were randomly assigned to a placebo group. The primary end point was the amount of 24-h blood loss. RESULTS: The amount of 24-h blood loss was significantly less in the TXA group than in the placebo group [mean (95% confidence interval): 18.6 (15.8-21.4) vs. 23.5 (19.4-27.5) ml/kg, respectively; mean difference -4.9 (-9.7 to -0.01) ml/kg; p = 0.049]. This effect of TXA was already significant at 6 h [9.5 (7.5-11.5) vs. 13.2 (10.6-15.9) ml/kg, respectively; mean difference -3.47 (-7.0 to -0.4) ml/kg; p = 0.027]. However, there was no significant difference in the amount of blood transfusion between the groups. There was also no statistical difference in the effect of TXA in each cyanotic and acyanotic subgroup. CONCLUSION: TXA can reduce blood loss in pediatric cardiac surgery but not the transfusion requirement (http://ClinicalTrials.gov number NCT00994994).

Impaired deformability might contribute to the accumulation of activated leukocytes within pulmonary microcapillaries, leading to acute lung injury. The purpose of our study was to investigate changes in leukocyte deformability during periods of inflammation after esophagectomy. The study group comprised 20 patients who underwent esophagectomy. Changes in leukocyte deformability were investigated by examining filtration through a silicon microchannel, which simulated human pulmonary microcapillaries. Changes in the neutrophil cytoskeleton were investigated by measuring neutrophil F-actin assembly. The severity of patient clinical outcome was evaluated by the lung injury score. Leukocyte filtration through the microchannel was significantly weaker in esophagectomy patients than in healthy subjects (p<0.01). After esophagectomy, filtration was further impaired compared with preoperative values (p<0.05). The neutrophil F-actin content was higher in patients than in controls (p<0.01), and increased after esophagectomy compared with preoperative values (p<0.01). We concluded that circulating leukocytes showed reduced deformability and appeared to be sequestered within microcapillaries after esophagectomy. Changes in neutrophil cytoskeleton were considered to be responsible for the reduced deformability. Leukocyte accumulation within pulmonary microcapillaries might be related to the pathogenesis of lung injury after esophagectomy.

先天性心疾患患者への腸回転異常修復術における麻酔を経験した。症例は2歳9ヵ月男児で、生後すぐに心雑音を指摘された。生後10日目に心エコー検査で無脾症、単心房、共通房室弁孔、両大血管右室起始、総肺静脈還流異常(TAPVC)、superior-inferior ventricleと診断され、TAPVC修復術、肺動脈絞扼術が施行された。生後7ヵ月で両方向性グレン手術とvertical vein ligationが施行された。今回、両大静脈肺動脈吻合法予定で入院したが、腸回転異常が認められ、入院後17日目に待機的に腸回転異常修復術を施行した。本症例の麻酔経過を述べ、このような患児の麻酔を安全に行うためには原疾患の血行動態を把握する必要があることを指摘した。非心臓手術の対象となる疾患の理解も必要である。

Human vascular endothelial cells form the interface between the bloodstream and vessel walls and are continuously subjected to mechanical stimulation. When endothelial cells are stretched cyclically, along one axis, they align perpendicular to the axis of stretch. We previously reported that applying a cyclic, uni-axial strain to cells induced tyrosine phosphorylation of focal adhesion kinase and stimulated mitogen-activated protein kinase. However, it is difficult to quantify and analyze the spatial distribution of tyrosine phosphorylation in these cells, as they form focal adhesions randomly. In this study, we developed a system to overcome this problem by preparing individual, uniform, patterned cells that could be stretched cyclically and uni-axially. We constructed polydimethylsiloxane stretch chambers and used microcontact printing technology to imprint a pattern of 2 microm fibronectin dots (10 lines x 10 columns in a 38 microm square) before seeding them with human umbilical vein endothelial cells (HUVEC). We found that most HUVEC attached to the patterned dots after 2h and were similar in size and morphology, based on phase-contrast microscopy. In this system we were able to statistically analyze tyrosine phosphorylation and actin polymerization in these patterned cells, when subjected to a cyclic, uni-axial strain, using fluorescent microscopy.

術後の疼痛はさまざまな悪影響を及ぼすため術後鎮痛は重要である.著者らはその方法として,主に硬膜外鎮痛法と静脈内patient controlled analgesia(PCA)を用いている.低濃度の局所麻酔薬とオピオイドを投与する硬膜外鎮痛法は非常に効果的であるが,静脈内PCAを選択する事も徐々に増えている.将来的にはAPS(acute pain service)による組織的な術後鎮痛を行う必要がある

66歳男性.患者は発熱および右足の発赤・疼痛を主訴に,近医を訪れ生剤投与を受けていた.しかし,血中クレアチニン(Cr)の上昇が出現したため,著者らのICUへ入院となった.入院時,右足趾間部に小水疱,左手首に腫脹,左膝部に発赤がを認められた.血液検査ではBUN,Cr,CRPの上昇,血小板,AT-IIIの低下,FDPの上昇を認め,DICが疑われた.血液培養と右趾間の培養では,A群β溶連菌が検出された.この時点では蜂窩織炎と判断し,ペニシリンG投与とともに補液を開始したが,入院4日目より尿量の減少,Crの再上昇とともにASO,ASKの上昇,CH50の低下を認めた.以上より,溶連菌感染後急性糸球体腎炎(PSAGN)と診断し,ドパミン,フロセミド,カルペリチド投与やCHDを行ったが無効であった.そこでステロイドパルス療法を2クール行ったところ,腎機能の改善がみられ,入院18日目にCHD離脱となり,26日目にはICU退室となった.副作用を注意して使用すればステロイドパルスはPSAGNに対して有効な治療法になりうると考えられた