原 著
Early postoperative hyperlactatemia in elective neurosurgical patients: A retrospective study

Hiroaki Yoshikawa^1)＊, Shinichi Nishibe²⁾, Daisuke Sakai³⁾, Hirokazu Imanishi⁴⁾, Seika Ohno¹⁾, Katsue Kobayashi⁵⁾, Akira Kitamura¹⁾,
1) Department of Anesthesiology, Saitama Medical University International Medical Center
2) Department of Anesthesiology, Tokyo Metropolitan Children’s Medical Center
3) Department of Anesthesiology, Chiba-Nishi General Hospital
4) Department of Anesthesiology, Tominaga Hospital
5) Division of Disability and Oral Health, Meikai University School of Dentistry

[Purpose] We occasionally encounter early postoperative hyperlactatemia during neurosurgery in the absence of hemodynamic instability or critical illness. We conducted a retrospective study to identify factors causing hyperlactatemia in elective neurosurgical patients and assessed the association between early postoperative hyperlactatemia and postoperative morbidity.
[Methods] The present study enrolled elective neurosurgical patients in whom an arterial blood gas analysis, including the measurement of lactate levels, had been performed at two-time points (i.e., after the induction of anesthesia and immediately before the surgery was completed). Early postoperative hyperlactatemia was defined as a lactate level of ≥ 2 mmol/L in arterial blood collected immediately before the completion of the surgery. Patients were divided into a high-lactate (HL) group, including those with early postoperative hyperlactatemia, and a normal-lactate (NL) group, including the remaining patients, and were compared. The following variables were retrieved from medical records: patient characteristics; perioperative vital signs; preoperative comorbidities; type of surgery; brain tumor pathology; size of brain tumor; preoperative comorbidities; duration of surgery; blood loss; PaO₂,PaCO₂, pH, and lactate; catecholamine use; length of stay in the ICU; mechanical ventilation requirement; and postoperative adverse events. Multiple logistic regression analysis was used to identify factors causing postoperative hyperlactatemia.
[Results] Two hundred and twenty-five patients were involved in this study. Early postoperative hyperlactatemia was observed in 49 of 225 (22%) patients. Brain tumor surgery, longer duration of surgery, preoperative hyperlactatemia, and larger blood loss volume were found to be more prevalent in the HL group than in the NL group, as per univariate analysis (P < 0.05). Risk factors for early postoperative hyperlactatemia were preoperative hyperlactatemia (odds ratio=27.83; 95% confidence interval=8.516-90.92, P=0.000) and brain tumor surgery (odds ratio=4.806; 95% confidence interval=1.006-21.67, P=0.041) in multiple regression analysis. Of the 225 patients, 89 patients underwent a craniotomy for the resection of a brain tumor. The sizes of the brain tumors in the HL group (1016 mm² [IQR: 545, 1951 mm²]) were significantly larger than those in the NL group (780 mm² [IQR: 322, 1107 mm²]) (P=0.02). Preoperative steroids and diuretics to reduce intracranial hypertension were more often prescribed for patients with high-grade tumors (P=0.01, P=0.07, respectively). Of the 49 patients in the HL group, 15 (31 %) stayed in the ICU for ≥ 2 days after surgery, whereas only 28 of 176 (16 %) patients in the NL group did (P < 0.05).
[Conclusion] Preoperative hyperlactatemia and brain tumor surgery are independent risk factors for early postoperative hyperlactatemia. Early postoperative hyperlactatemia is associated with a longer length of stay in the ICU. The role of early postoperative hyperlactatemia as a predictor of adverse postoperative complications in neurosurgical patients needs to be investigated further in future studies.

J Saitama Medical University 2018; 45(1): 1-11
(Received April 25, 2017 / Accepted February 15, 2018)

Keywords: hyperlactatemia, brain tumor, Warburg effect, neurosurgery

症例報告
フレカイニドが有効であった多源性心房頻拍の新生児の一例

大島　あゆみ^＊，石黒　秋生，
1) 埼玉医科大学病院 小児科
埼玉医科大学総合医療センター　小児科

〔平成30年3月2 日受付／平成30年5月23日 受理〕

　多源性心房頻拍（multifocal atrial tachycardia, MAT）は心房における複数起源とする自動能の異常亢進により生じる稀な不整脈である．多くは無治療のまま自然消退するが，治療抵抗性である症例も散見される．我々は治療抵抗性の MAT の新生児例を経験した．胎児期より胎児水腫を指摘されていた．日齢 3 より頻脈性不整脈が出現し，複数の抗不整脈薬を投与したが再燃を繰り返していた．日齢 22 に MAT と診断後フレカイニドの投与を行い洞調律化に成功した．その後フレカイニドとランジオロールの二剤のみで洞調律を維持した．

Management of multifocal atrial tachycardia in a newborn baby by flecainide

Ayumi Oshima^1)＊, Akio Ishiguro
Department of Pediatrics, Saitama Medical Center, Saitama Medical University

J Saitama Medical University 2018; 45(1): 12-17
（Received March 28, 2018/Accepted May 23, 2018）

Keywords: atrial arrhythmia, neonatal

症例報告
動脈管クリップによる左主気管支圧排のために左無気肺を来たした超低出生体重児の1例

岡　俊太郎^1)＊，川崎　秀徳²⁾，金井　雅代¹⁾，石黒　秋生¹⁾，加部　一彦¹⁾，側島　久典¹⁾，田村　正徳¹⁾
1) 埼玉医科大学総合医療センター　小児科
2) 京都大学医学部附属病院　遺伝子診療部

〔平成30年3月29日 受付／平成30年5月30日 受理〕

　在胎24週6日，669gにて出生した女児．動脈管開存症（PDA）に対して日齢5に動脈管クリッピング術を施行し，術後に左完全無気肺を認めた．
　気道の評価目的で日齢64に気管支鏡検査を行ったところ，左主気管支の内腔が右に比べ細く，外側からの圧排所見を認めた．また，同日施行した胸部CTにて，左主気管支に近接して動脈管クリップが位置しているのを確認した．以上より，動脈管閉鎖術に用いたクリップが左気管支を圧排していると判断した．左無気肺はAirway pressure release ventilation（APRV）による呼吸管理を行うことで改善を得た．日齢65に抜管し，経鼻的持続陽圧換気（N-CPAP）による呼吸補助を開始した．日齢77に呼吸補助をhigh flow nasal canula（HFNC）に変更した．抜管後は無気肺の再発を認めず，日齢141に修正44週，体重2466gで，慢性肺疾患に対して在宅酸素療法を導入して退院となった．

A case of an extremely low birth weight infant with left lung atelectasis resulting from obstruction of the left main bronchus PDA closure

Shuntaro Oka^1)＊, Hidenori Kawasaki²⁾, Masayo Kanai¹⁾, Akio Ishiguro¹⁾, Kazuhiko Kabe¹⁾, Hisanori Sobajima¹⁾, Masanori Tamura¹⁾
1) Department of Neonatology, Saitama Medical Center, Saitama Medical University
2) Department of Genetics, Kyoto University Hospital

J Saitama Medical University 2018; 45(1): 18-21
（Received March 29, 2018/Accepted May 30, 2018）

Keywords: PDA clipping, postoperative complications, atelectasis, bronchial obstruction, bronchoscopy