Katsunori Oe

Rationale: Gross Type C congenital esophageal atresia is associated with tracheoesophageal fistula (TEF). Perioperative airway management, including prevention of aspiration of gastric contents, is important. Generally, the TEF is blocked by 1-lung intubation of the dependent lung, or directly by insertion of a balloon catheter. This case report describes successful management of TEF by insertion of a balloon catheter via tracheostoma in an infant with a difficult airway. Patient concerns: A boy with trisomy 18 underwent esophageal banding and gastrostomy for Gross Type C congenital esophageal atresia on postnatal day 3. Tracheostomy was performed on day 49, and definitive surgery for TEF was scheduled on day 83. Diagnoses: The boy was diagnosed with Gross Type C congenital esophageal atresia shortly after birth. Interventions: The patient was re-intubated orotracheally in the NICU. Oral insertion of a 4Fr Fogarty catheter to block the TEF was difficult. Insertion through the available tracheostoma was easier. Outcomes: We confirmed that the catheter could be guided to the TEF entrance using a bronchoscope, and the balloon was expanded to block the TEF. During surgery, there were no problems with airway management. Lessons: In the management of TEF in children after tracheostomy, if oral insertion of the balloon catheter proves difficult, insertion via the tracheostoma may be effective.

Bernard‐Soulier syndrome (BSS) is a platelet dysfunction disorder characterized by massive thrombocytopenia and a lack of platelet aggregation. Remimazolam, a short‐acting benzodiazepine sedative, is believed to have minimal effects on platelets. Here, we report the safe use of remimazolam for anesthesia management in a patient with BSS.

Optimal positive end-expiratory pressure (PEEP) can induce sustained lung function improvement. This prospective, non-randomized interventional study aimed to investigate the effect of individualized PEEP determined using electrical impedance tomography (EIT) in post-cardiac surgery patients (n = 35). Decremental PEEP trials were performed from 20 to 4 cmH₂O in steps of 2 cmH₂O, guided by EIT. PEEP levels preventing ventilation loss in dependent lung regions (PEEP_ONLINE) were set. Ventilation distributions and oxygenation before the PEEP trial, and 5 min and 1 h after the PEEP_ONLINE setting were examined. Furthermore, we analyzed the saved impedance data offline to determine the PEEP levels that provided the best compromise between overdistended and collapsed lung (PEEP_ODCL). Ventilation distributions of dependent regions increased at 5 min after the PEEP_ONLINE setting compared with those before the PEEP trial (mean ± standard deviation, 41.3 ± 8.5% vs. 49.1 ± 9.3%; p < 0.001), and were maintained at 1 h thereafter (48.7 ± 9.4%, p < 0.001). Oxygenation also showed sustained improvement. Rescue oxygen therapy (high-flow nasal cannula, noninvasive ventilation) after extubation was less frequent in patients with PEEP_ONLINE ≥ PEEP_ODCL than in those with PEEP_ONLINE < PEEP_ODCL (1/19 vs. 6/16; p = 0.018). EIT-guided individualized PEEP stabilized the improvement in ventilation distribution and oxygenation. Individual PEEP varies with EIT measures, and may differentially affect oxygenation after cardiac surgery.

It has been reported that PECS II block can alleviate postoperative pain following transapical transcatheter aortic valve implantation (TA-TAVI). However, the effectiveness of continuous PECS II block with catheterization has not yet been reported on the postoperative pain in patients undergoing TA-TAVI. We experienced two cases of TA-TAVI who received PECS II block with catheterization to manage postoperative pain. In the first case, a bolus injection for intraoperative pain and subsequent catheterization were performed before the implantation. However, the patient developed severe pain postoperatively in spite of the continuous block due to displacement of the catheter. In the second case, a bolus injection and the catheterization for the continuous block were performed before and after the implantation, respectively, which provided high-quality pain control. Continuous PECS II block may be useful to control perioperative pain associated with TA-TAVI. The insertion of the catheter after the implantation could be useful to avoid its displacement during the surgery.