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ABSTRACT: 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.
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.
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.
TXA can reduce blood loss in pediatric cardiac surgery but not the transfusion requirement (http://ClinicalTrials.gov number NCT00994994).
Journal of Anesthesia 09/2011; 25(6):823-30. · 0.83 Impact Factor
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ABSTRACT: A male child, aged 1 year, with pulmonary atresia, ventricular septal defect and major aorto-pulmonary collateral arteries (PA, VSD, MAPCA) underwent corrective surgery including MAPCA ligation uneventfully. A few hours after admission to the ICU, severe heart failure, refractory to aggressive cardiac support including epinephrine infusion, became worse. Emergent cardiac catheterization on postoperative day 5 demonstrated the residual MAPCA and its occlusion by coil embolization dramatically resolved heart failure, indicating that the primary cause of this hemodynamic instability was likely excessive left-to-right shunt due to MAPCA. Residual LR shunt should be kept in mind to be a rare but significant cause of postoperative serious heart failure.
Masui. The Japanese journal of anesthesiology 11/2010; 59(11):1441-5.
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ABSTRACT: Amiodarone is widely used in Europe and the United States for refractory ventricular fibrillation (VF) in various situations, such as VF after myocardial infarction or out-of-hospital cardiac arrest. We report a case of successful treatment with amiodarone of refractory VF immediately after releasing aortic cross-clamp in cardiac surgery. A 66-year-old man suffering from severe aortic stenosis underwent aortic valve replacement (AVR). General anesthesia was induced with propofol and remifentanil, and subsequently AVR was performed under cardiopulmonary bypass. Just after releasing aortic cross-clamp, VF occurred, and it continued despite multiple trials of cardioversion with direct current (DC) shocks of 20 J or 30 J. Furthermore, some DC shocks of 30 J or 50 J after administering lidocaine 60 mg and 0.5 mol x l(-1) magnesium sulfate 20 ml were also ineffective. Then, nifekalant 20 mg was administered and DC shocks of 50 J were repeated intermittently, but VF still persisted. Eventually, VF disappeared after a final DC shock of 50 J with intravenous amiodarone 125 mg. Overall duration of VF was 60 minutes. The patient's trachea was extubated three days after the surgery without any complications. Intravenous amiodarone may be one of the most useful remedies for some types of arrhythmias including persistent VE.
Masui. The Japanese journal of anesthesiology 10/2010; 59(10):1266-70.
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ABSTRACT: Hypoplastic left heart syndrome (HLHS) with intact atrial septum (IAS) is an extreme type of single ventricle physiology among congenital heart diseases, in which a baby cannot supply oxygenated blood into systemic circulation without alternative pathway. We report the case of the neonate undergoing open balloon atrial septostomy (BAS) and bilateral pulmonary artery banding (PAB) soon after scheduled caesarean sections (C/S). A 35-year-old female was pregnant and fetal echocardiography at 32 weeks revealed one of the twins as HLHS/IAS. Severe hypoxia soon after birth was suspected. Thus, scheduled C/S followed by open BAS was planned. At 36 weeks of gestation, the mother was anesthetized with spinal bupivacaine and the female baby with HLHS/IAS was delivered. After diagnosed definitely by pediatric cardiologists, her trachea was intubated by anesthegiologists and umbilical catheters were placed by neonatologists. Then the baby was transferred to neighboring operating theater for BAS 68 minutes after the birth, while her Sp(O2) was maintained around 75-85% through serial procedures. Open BAS and PAB were performed under general anesthesia without any hemodynamic instability or severe hypoxia. Cooperation among anesthegiologists, neonatologists, pediatric cardiologists, and cardiac surgeons is mandatory in order to successfully complete such a rushed procedure.
Masui. The Japanese journal of anesthesiology 10/2010; 59(10):1308-10.
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ABSTRACT: Insulinomas are rare tumors, the incidence of which is 1-2 per million. Patients with insulinomas present with symptoms of hypoglycemia secondary to insulin hypersecretion. Surgical resection is a treatment of choice and offers the only chance of cure. The important points in anesthesia are the precaution against hypoglycemia until tumor resection and the control of rebound hyperglycemia soon after tumor resection. We report the anesthetic management of a 5-year-old patient with insulinoma. Soon after the induction of anesthesia, the continuous glucose monitoring was commenced. Until the tumor resection, 10% glucose infusion was required to avoid hypoglycemia. Then, insulin infusion was continued to maintain blood glucose level around 150 mg x dl(-1). All glucose management was guided with continuous glucose monitoring. This is a first case report to show the feasibility and usefulness of continuous glucose monitoring in management of pediatric insulinoma patients. As the blood glucose was dramatically altered during perioperative period, frequent blood glucose measurements or continuous glucose monitoring is mandatory during perioperative period of insulinoma resection.
Masui. The Japanese journal of anesthesiology 07/2009; 58(6):757-9.
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Moritoki Egi,
Hiroshi Morimatsu,
Christian J Wiedermann,
Makiko Tani,
Tomoyuki Kanazawa, Satoshi Suzuki,
Takashi Matsusaki,
Kazuyoshi Shimizu,
Yuichiro Toda,
Tatsuo Iwasaki,
Kiyoshi Morita
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ABSTRACT: Validation of a scoring algorithm for non-overt disseminated intravascular coagulation (DIC) proposed by the International Society on Thrombosis and Haemostasis (ISTH) is still incomplete. It was the objective of this study to assess the impact of including AT to non-overt DIC scoring on the predictability for intensive care unit (ICU) death and the later development of overt-DIC defined by the Japanese Ministry of Health and Welfare (JMHW) or the ISTH. We performed a retrospective observational study conducted in 364 patients in critical care. Coagulation parameters obtained daily for DIC screening were utilised for scoring. There were 194 and 196 patients scored as positive non-overt DIC with and without AT, respectively; diagnostic agreement between the two was 78%. As compared with patients without non-overt DIC, these non-overt DIC patients had significantly higher mortality. In 37 ICU non-survivors, positive non-overt DIC scoring with AT preceded ICU death by a median of 6.8 days, which was significantly earlier as compared with a median of 5.4 days for non-overt DIC without AT (p = 0.022). In patients who developed overt-DIC after admission, the time period from positive non-overt DIC to positive overt-DIC was significantly longer when AT was utilised (overt-DIC ISTH; 1.3 days vs. 0.1 days, p = 0.004, overt-DIC JMHW; 2.5 days vs. 2.0 days, p = 0.04, with AT vs. without AT, respectively). Non-overt DIC scoring predicted a high risk of death in critically ill patients. When information on AT levels was included, non-overt DIC scoring was found to predict development of overt-DIC significantly earlier than non-overt DIC scoring without AT.
Thrombosis and Haemostasis 05/2009; 101(4):696-705. · 5.04 Impact Factor
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ABSTRACT: We aimed to clarify the acid-base abnormalities of patients with acute kidney injury (AKI) requiring peritoneal dialysis (PD) in pediatric cardiac care units.
A retrospective observational study was conducted in a pediatric cardiac care unit in a tertiary care university hospital. The subjects were 40 patients with AKI requiring PD between 2003 and 2005, and controls matched by type of surgery and body weight. Acid-base variables, including blood gas data and electrolytes, were assessed. The Stewart-Figge variables, including strong ion difference apparent (SIDa), strong ion difference effective (SIDe), and strong ion gap (SIG), were calculated.
Blood gas analyses showed that the PD group was more acidemic, with a lower mean bicarbonate and a lower mean base excess, typical features of metabolic acidosis. The strong ion analyses revealed that the PD group had lower mean sodium and albumin concentrations. Based on the Stewart-Figge methodology, SIDa was smaller in the PD group than in the control group, but SIG was similar in the two groups. Receiver-operating characteristic curve analyses showed that serum albumin was the only prognostic factor associated with PCCU mortality, even after adjustment for PD treatment.
Patients with AKI requiring PD in a pediatric cardiac care unit had significant metabolic acidosis compared to controls matched by the type of surgery and body weight. Hyponatremia and hypoalbuminemia were characteristics of these patients. The calculated SIDa was smaller in the PD than in the control group. Only the serum albumin had a significant prognostic value.
Journal of Anesthesia 02/2009; 23(3):334-40. · 0.83 Impact Factor
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ABSTRACT: The progression and interrelationship of mediators that are released, activated or suppressed after major surgery appear to play an important role in responses to surgical stress. Heat shock protein 70 (HSP70) is stress-induced and acts like a cytokine to modulate pro-inflammatory mediators, such as tumor necrosis factor-α (TNF-α) and inducible nitric oxide synthase (iNOS), by stimulating toll-like receptor 4 (TLR4) signaling. We hypothesized that this effect would occur after major surgery, such as esophagectomy. We therefore measured the expression of HSP70, TLR4, TNF-α and iNOS mRNA in peripheral blood mononuclear cells (PBMCs) from 11 patients who underwent esophagectomy with thoracoabdominal procedures at postoperative day (POD) 1 and POD3 using real-time polymerase chain reaction, and compared the results to expression levels in 6 healthy adult volunteers (controls). We also measured plasma cortisol as a well-known stress hormone. The expression of HSP70 mRNA in PBMCs was 2.1-fold higher on POD1 compared to the controls (P=0.041) and was positively correlated with TLR4 mRNA (r2=0.45, P=0.0007). The expression of TNF-α mRNA tended to be lower on POD1 (P=0.055) and was significantly decreased on POD3 (P=0.016), and iNOS mRNA were significantly lower on POD1 (P=0.0015) and POD3 (P=0.0003) compared to the controls. Moreover, there was a positive correlation between the expression of TLR4 mRNA and plasma cortisol levels (r2=0.24, P=0.021). The expression of HSP70 mRNA in PBMCs in the early postoperative period was significantly higher and positively correlated with TLR4 mRNA. This suggests that HSP70-TLR4 signaling has an important role in postoperative inflammatory responses. However, the expression of pro-inflammatory mediators, including TNF-α and iNOS mRNA, was significantly decreased postoperatively. This may be caused by the anti-inflammatory mechanism of cortisol. Our findings indicate that responses to surgical stress reflect simultaneous pro-inflammatory and anti-inflammatory responses, and are complex.
Molecular Medicine Reports 3(5):765-9. · 0.42 Impact Factor
