Masui. The Japanese journal of anesthesiology
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Case Reports
[Perioperative management of a case of myasthenic crisis with unexpected difficult airway].
Myasthenia gravis (MG) is an autoimmune disorder characterized by loss of acetylcholine receptors (AChR) due primarily to the production of anti-AChR autoantibodies. We report here a case of anesthetic management of MG patient associated with difficult airway. A 58-year-old woman, 150 cm in height and 43 kg in weight, was scheduled for elective thymectomy. ⋯ We used fiberscope intubation for her because it was difficult to intubate."Cannot intubate, cannot ventilate (CICV)" scenario is very rare, but it sometimes leads to serious morbidity and mortality. Therefore, we need to deal with this emergency situation by using a variety of equipments and techniques. Careful examination of the airway and a carefully considered plan for re-intubation are prerequisites for this type of surgery.
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Development of pulse oximeter technology has made it possible to measure total hemoglobin noninvasively. The use of Radical-7 would improve patient care in emergency medicine and chronic internal medicine as well as perioperative medicine, and could reduce the burden of the patient.
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Pulse oximeter expressed by SpO2 is used for monitoring respiratory state during operation and in ICU. Perfusion index (PI) and pleth variability index (PVI) as new indexes are calculated from pulse oximeter (Masimo SET Radical-7, Masimo Corp., USA, 1998) waveforms. And these indices were used as parameters to evaluate the circulatory state. ⋯ It might thus be of future value in assessment of perioperative changes in peripheral perfusion. PVI is a measure of a dynamic change in PI that occurs during complete respiratory cycle. It might be thought that PVI, an index automatically derived from the pulse oximeter waveform analysis, had potentially clinical applications for noninvasive hypovolemia detection and fluid responsiveness monitoring.
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It is difficult to maintain well-balanced stability of respiratory and hemodynamic functions in critically ill patients. The PiCCO system (Pulsion Medical Systems, Munich, Germany) for hemodynamic and respiratory monitoring has been available clinically in Japan since 2000. ⋯ The PiCCO system is mainly used in intensive care for patients with sepsis, septic shock and cardiogenic shock. Further clinical investigations are required to confirm that estimating PiCCO parameters such as ITBVI, EVLWI and PVPI may help to better characterize, guide, and improve the treatment of critically ill patients.
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Noninvasive monitoring of regional cerebral oxygen saturation has been introduced in clinical settings for estimation of cerebral perfusion and cerebral blood flow. In this article, I have described several issues regarding the usefulness and clinical limitations associated with the use of these monitors, as well as relevant information on basic principles of monitoring. At present, there is not enough clinical data concerning critical levels of measured variables that are essential for safe perioperative management of patients susceptible for cerebral ischemia.