Obesity is perceived as a risk factor in general thoracic surgery. We conducted a single-center retrospective evaluation of perioperative complications in 822 patients who underwent thoracic surgery between 2000 and 2005. According to body mass index, 82 were underweight (< 18.5 kg m(-2)), 568 were normal (18.5-24.9 kg m(-2)), 155 were overweight (25.0-29.9 kg m(-2)), and 17 were obese (>or=30 kg m(-2)). A significant increase in preoperative comorbidity (hypertension and ischemic heart disease) was observed with increasing body mass index. There was no significant difference in operation time or length of stay in the operating room, but extubation time was significantly different among the 4 groups. Of the intraoperative complications, alveolar-arterial oxygen difference increased significantly with increasing obesity, and hypoxia was least common in the normal group. Postoperatively, there was more pulmonary leakage in the underweight group and less pneumonia in the normal group. Both the underweight and the obese are at increased risk of perioperative complications and need to be carefully observed and managed intraoperatively and postoperatively.
Aortocaval fistula is a rare complication of ruptured abdominal aortic aneurysm (AAA), and patients with an aortocaval fistula show multiple symptoms. We report an 87-year-old man who was diagnosed as having an AAA with aortocaval fistula and who developed refractory hypotension after induction of anesthesia. Following a phenylephrine injection for slight hypotension induced by anesthetic induction, he developed severe hypotension and bradycardia, and his skin became cyanotic. Vasopressor agents had no immediate effect on the hypotension, but blood pressure gradually increased in about 30 min with continuous infusion of dopamine and noradrenaline. Transesophageal echocardiography (TEE) showed right ventricle (RV) hypokinesis and massive tricuspid regurgitation (TR). Central venous pressure (CVP) showed a remarkably high value. After the repair of the aortocaval fistula, the hemodynamics became stable, RV motion was improved, TR was reduced, and CVP became normal. Anesthetic management of the repair of an aortocaval fistula is very difficult. The hemodynamics changed dramatically throughout anesthesia in our patient with this disorder, even though low-dose anesthetics were used. For the successful treatment of this disorder, preparation for the operation is required before the induction of anesthesia, and urgent closure of the fistula is necessary after the induction of anesthesia. TEE is a useful tool for monitoring hemodynamics in such patients.
A seven-month-old male infant who was diagnosed with inguinal hernia at routine medical checkup was admitted to our hospital for surgical repair. Past history and family history were negative for bleeding tendencies, purpura, and hemophilia. Preoperative physical examination and laboratory tests indicated no abnormalities. Coagulation tests were not performed.Hernioplasty was performed with no oozing or complications. The patient was discharged from the operating room at 4 p.m. At 7 a.m. on postoperative day (POD) 1, HR had increased to 132 bpm and BP decreased to 90/40 mmHg. The mother noticed blood contamination of the gauze covering the wound at night, but she did not inform the medical staff. At 9 a.m. on POD1, the attending surgeon noticed the patient to be extremely pale and that the gauze covering the wound was soaked with blood. Blood tests confirmed severe anemia (hemoglobin (Hb) 4.8 g/dl). Emergency hemostasis was performed immediately under general anesthesia. After failure to secure another peripheral venous access, we inserted a central venous catheter in the right internal jugular vein. Preparation of red cell concentrate (RCC) took a long time because blood type screening had not been conducted preoperatively. The coagulation tests showed long APTT (125 s), and thus fresh frozen plasma was transfused. Oozing was observed throughout the surgical field. The blood loss measured intraoperatively was 50 g and laboratory tests at the end of surgery showed Hb 8.9 g/dl, and Ht 26.4% after transfusion of two units of RCC. On POD2, the scrotum began to swell because of oozing which required removal of the stitches to reduce the pressure. On POD6, plasma clotting factor IX was reduced to 8% of the normal value, and he was diagnosed as hemophilia B. Therefore, clotting factor IX was transfused which resulted in complete cessation of oozing on POD11. The patient was discharged on POD26.Routine preoperative management does not include coagulation tests, especially before minor pediatric surgery, for example hernioplasty, for children with no family history of bleeding disorders. Routine use of coagulation tests have been discussed by otorhinolaryngologists who perform elective tonsillectomy and adenoidectomy. Houry et al.[1] and the American Academy of Otolaryngology Head Neck Surgery [2] recommended performing preoperative hemostatic screening tests only for patients with abnormal bleeding history. The reported negative predictive value of normal APTT in the absence of symptoms and
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