Journal of anesthesia
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Journal of anesthesia · Aug 2014
Case ReportsFatal pulmonary embolism following spinal surgery in a patient with permanent inferior vena cava filter placement.
It has been proven that the use of an inferior vena cava filter (IVCF) is effective in decreasing the incidence of pulmonary embolism (PE) in high-risk spinal surgery patients. A case of fatal PE after spinal surgery in a 78-year-old woman who had a history of pulmonary hypertension due to peripheral PE treated with a permanent IVCF and anticoagulant therapy for 3 years is reported. The patient had experienced an episode of recurrent PE during the withdrawal of anticoagulants, but she had uneventfully undergone two orthopedic surgeries with a preoperative unfractionated heparin infusion instead of oral warfarin. ⋯ The patient died 2 h and 30 min after onset. Acute PE probably occurred because of a massive thrombus above the IVCF. This case suggests that the efficacy of long- term use of a permanent IVCF is limited in cases when anticoagulants must be withdrawn, such as for orthopedic surgery.
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Journal of anesthesia · Aug 2014
Case ReportsPostsurgical coagulopathy in a hemophilia A patient with inhibitors: efficacy of recombinant factor VIIa.
Perioperative hemostatic management in patients with hemophilia A who develop the coagulation factor VIII (FVIII) inhibitor is challenging, because exogenous FVIII is neutralized, which boosts the inhibitor to provoke postoperative coagulopathy. Recombinant activated factor VII (rFVIIa) has become available for this type of patient, although FVIII is sometimes required. We treated a 56-year-old male patient with hemophilia A with FVIII inhibitor scheduled for total hip arthroplasty (THA) and total knee arthroplasty (TKA). ⋯ The amount of bleeding during TKA was 1,340 ml, while the level of the inhibitor increased to a greater level than that after THA, provoking uncontrollable bleeding. For anesthetic management in hemophilia A patients with FVIII inhibitor, anesthesiologists must pay attention to postoperative coagulopathy, and every effort should be used to minimize exposure to FVIII. Furthermore, when rFVIIa is ineffective, postponement of surgery until rFVIIa regains its efficacy may be beneficial as compared to an operation with FVIII.
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Journal of anesthesia · Aug 2014
Accidental dural puncture, postdural puncture headache, intrathecal catheters, and epidural blood patch: revisiting the old nemesis.
One of the controversial management options for accidental dural puncture in pregnant patients is the conversion of labor epidural analgesia to continuous spinal analgesia by threading the epidural catheter intrathecally. No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. To investigate whether the intrathecal placement of an epidural catheter following accidental dural puncture impacts the incidence of postdural puncture headache (PDPH) and the subsequent need for an epidural blood patch in parturients. ⋯ In contrast, 7 (13 %) of parturients in the ITC group required an EBP. The incidence of EBP was calculated in parturients who actually developed headache to be 57 of 99 (57 %) in the non-ITC group versus 7 of 20 (35 %) in the ITC group (OR, 2.52; 95 % CI, 0.92-6.68; P = 0.07). The insertion of an intrathecal catheter following accidental dural puncture decreases the incidence of PDPH but not the need for epidural blood patch in parturients.
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Journal of anesthesia · Aug 2014
Case ReportsPerioperative management of factor XI deficiency in a patient undergoing hip arthroplasty.
Factor XI deficiency, or hemophilia C, is a rare autosomal recessive bleeding disorder often diagnosed by inappropriate bleeding associated with trauma or a surgical procedure, and reports of anesthetic management of this disorder are rare. We experienced an 85-year-old man with femoral neck fracture who was diagnosed preoperatively with factor XI deficiency based on abnormally long activated partial thromboplastin time (APTT). He was scheduled for bipolar hip arthroplasty and was prepared for surgery by transfusion of fresh frozen plasma (FFP), instead of factor XI concentrates, which are not commercially available in Japan. ⋯ Transfusion of FFP shortened the APTT to a level sufficient to allow hemostasis, although not to within the normal range. Although the patient required transfusion of 2 units of RCC postoperatively, no bleeding complications occurred. For bipolar hip arthroplasty, transfusion of FFP produced sufficient hemostasis without the use of tranexamic acid, factor VII preparations, or desmopressin.
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Journal of anesthesia · Aug 2014
Sevoflurane induces cardioprotection through reactive oxygen species-mediated upregulation of autophagy in isolated guinea pig hearts.
Sevoflurane increases reactive oxygen species (ROS), which mediate cardioprotection against myocardial ischemia-reperfusion injury. Emerging evidence suggests that autophagy is involved in cardioprotection. We examined whether reactive oxygen species mediate sevoflurane preconditioning through autophagy. ⋯ Sevoflurane induces cardioprotection through ROS-mediated upregulation of autophagy.