Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study.

PURPOSE: Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. METHODS: The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. RESULTS: The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. CONCLUSION: These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.

Treatment of Ezetimibe lowers total and low-density lipoprotein cholesterol in hypercholesterolemic dogs with hyperadorenocorticism.

Ezetimibe is a cholesterol absorption inhibitor that blocks the intestinal absorption of both biliary and dietary cholesterol, thereby lowering primarily low density lipoprotein-cholesterol (LDL-chol) in human studies. This study aimed to investigate the effects of ezetimibe on dyslipidemia control in nine dogs with hypercholesterolemia. Changes in total cholesterol (T-chol) and each lipoprotein fractions were evaluated at 0, 2, and 4 months following initiation of ezetimibe treatment. A significant decrease in T-chol was observed, and a mean T-chol concentration below 400 mg/dL was achieved at 2 and 4 months. Furthermore, a significant decrease in LDL-chol was observed (-53.3% and -64.3% at 2 and 4 months, respectively). Taken together, treatment of ezetimibe could lower LDL-chol levels in dogs with hypercholesterolemia.

A Case of Takotsubo Cardiomyopathy Diagnosed After Postponement of Surgery Due to Hypotension and Electrocardiogram Abnormality Upon Entering the Operating Room.

Takotsubo cardiomyopathy (TCM) is a rare disease that is difficult to diagnose. We experienced a case that developed just before surgery. A woman in her 80s with no complications except hypertension was scheduled for colon cancer surgery. Although she was asymptomatic, after entering the operating room, her surgery was canceled due to unexplained hypotension and ST-segment elevation on the electrocardiogram monitor. Emergency coronary angiography was performed immediately, and the presence of TCM was revealed. Her surgery was therefore performed after the improvement in her cardiac function. Once a patient is in the operating room, the normalcy bias kicks in and it becomes difficult to decide to stop the surgery. However, even at this time, it is important to stop the induction of anesthesia if there is any abnormality and to make a differential diagnosis based on the possible development of a serious disease, as seen in this case.

Successful treatment of feline hyperadrenocorticism with pituitary macroadenoma using radiation therapy: a case study.

A 10-year-old castrated male cat showing behavioral (irritation, prowling, and tumbling) and cutaneous abnormalities such as dermal fragility was diagnosed as hyperadrenocorticism with pituitary macroadenoma, concurrent with insulin dependent diabetes mellitus. Pituitary enlargement (18.0 mm) was observed during magnetic resonance imaging. High endogenous adrenocorticotropic hormone levels (>2,500 pg/ml) were also observed. Although trilostane treatment (5-10 mg/head, daily) was commenced, the clinical signs did not disappear. Insulin and trilostane treatment were discontinued on day 86 after first day of radiation therapy (4 Gy/12 fractions). After radiation therapy, a decreased pituitary tumor size (10.7 mm) was observed on day 301; neurological and dermatological signs exhibited remission. Radiation therapy is the treatment of choice for feline hyperadrenocorticism with pituitary macroadenoma with neurological signs.

Two Cases of Liver Transplantation With a High Ionized Magnesium to Total Magnesium Ratio.

Magnesium (Mg), an important cation, is involved in the activation of enzymes important for life support. The incidence of hypomagnesemia in critically ill patients admitted to the intensive care unit (ICU) is high and has been reported to be a factor in worsening prognosis. Ionized magnesium (iMg) is physiologically active, although total magnesium (tMg) is often used to evaluate the concentration of magnesium because of the limited availability of instruments that can measure iMg. However, the changes in tMg and iMg are not correlated in critically ill patients. We obtained considerable data on the simultaneous measurements of iMg and tMg in two patients with severe liver disease who underwent liver transplantation. In both patients, the iMg/tMg values were high, suggesting the influence of hypoalbuminemia associated with liver dysfunction. Mg correction using tMg as a guide may lead to overdose. Furthermore, when considering the data for each case, the correlation between iMg and tMg was very high, which suggested that the iMg/tMg ratio may be a value unique to each individual or disease. Investigating in a large-scale study the correlation between iMg levels and clinical symptoms and prognosis is necessary in the future.

Ionized Hypomagnesemia Is Associated With Increased Incidence of Postoperative Atrial Fibrillation After Esophageal Resection: A Retrospective Study.

INTRODUCTION: Postoperative atrial fibrillation (POAF) is common after surgery for esophageal cancer and may prolong hospitalization and elevate mortality. POAF and hypomagnesemia are linked, but this is based on studies showing an association of POAF with serum total magnesium (tMg). In contrast, the relationship of POAF with ionized magnesium (iMg), which has physiological activity, has not been examined. In this study, the association between hypomagnesemia and POAF was investigated retrospectively to examine iMg as a possible predictive factor for POAF. METHODS: The subjects were 151 patients who underwent right transthoracoabdominal subtotal esophagectomy at Saitama Medical Center between January 2011 and December 2020. The incidence of POAF and predictive factors were examined retrospectively. Perioperative predictive factors were subjected to univariate analysis, and items with P<0.1 were then included in multivariate analysis, along with five potential POAF predictors reported in the literature (age, gender, body mass index, hypertension, and diabetes mellitus). P<0.05 was regarded as significant in the multivariate analysis. RESULTS: Of the 151 patients, 34 (23%) developed POAF. In univariate analysis, six factors with P<0.1 (oral statin, dyslipidemia, iMg level after anesthesia induction, maximum and minimum iMg during surgery, and iMg level immediately before admission to ICU) were identified. In multivariate analysis including these and the five literature factors as explanatory variables, iMg immediately before admission to ICU emerged as a predictive factor for POAF (iMg≥0.46 mmol/L, OR 0.32, 95%CI 0.14-0.74, p=0.01) (standard iMg range: 0.48-0.60 mmol/L). CONCLUSION: The iMg level immediately before admission to ICU may be associated with the development of POAF. A further study is needed to evaluate changes in iMg in the ICU and iMg at the time of onset of POAF.

Intermittent Urine Oxygen Tension Monitoring for Predicting Acute Kidney Injury After Cardiovascular Surgery: A Preliminary Prospective Observational Study.

Introduction Novel biomarkers of acute kidney injury (AKI) are being developed and commercialized. However, none are universally available. The aim of this preliminary prospective observational study was to explore the effectiveness of intermittent urine oxygen tension (PuO2) monitoring without special equipment (using a blood gas analyzer) for predicting AKI after elective cardiovascular surgery requiring cardiopulmonary bypass (CPB). Methods Fifty patients who underwent elective cardiovascular surgery requiring CPB were enrolled in the study with written informed consent. Urine samples were intermittently collected from a urethral catheter at four points: T1, immediately after induction of general anesthesia in the operating room; T2, immediately after intensive care unit (ICU) admission; T3, six hours after ICU admission; and T4, 12 hours after ICU admission. PuO2 was measured with a blood gas analyzer. The Kidney Disease Improving Global Outcomes classification was used for the diagnosis of AKI, then patients were followed up until postoperative day 7. By generating the receiver operating characteristic curves, the cut-off value of PuO2 and area under the curve (AUC) for predicting the onset of AKI was calculated. The odds ratio (OR) and 95% confidence interval (CI) of each time point were calculated using logistic regression analysis or exact logistic regression method. P < 0.05 was considered significant. Results Twelve patients were diagnosed with AKI (24% morbidity). The cut-off values of PuO2 for predicting onset of AKI at the four time points were T1, PuO2 ≥ 132.4 mmHg (OR 3.1, 95% CI 0.78-12.0, p = 0.11, AUC 0.57); T2, PuO2 ≥ 153.3 mmHg (OR 5.8, 95% CI 1.08-31.4, p = 0.04, AUC 0.51); T3, PuO2 ≥ 130.1 mmHg (OR 0.19, 95% CI 0.05-0.75, p = 0.018, AUC 0.68); T4, PuO2 ≥ 88.6 mmHg (OR 0.07, 95% CI 0-0.486, p = 0.011, AUC 0.64). Conclusion Intermittent PuO2 values at six and 12 hours after ICU admission may be predictors of AKI, although the AUCs to predict AKI were low (0.68 and 0.64). AKI prediction by PuO2 was not possible immediately after induction of general anesthesia (not statistically significant) and immediately after ICU admission (AUC was very low). Further studies are required to confirm the validity of intermittent PuO2 monitoring.

Successful Management of Refractory Torsades De Pointes Due to Drug-Induced Long QT Syndrome Guided by Point-of-Care Monitoring of Ionized Magnesium.

Ionized magnesium (iMg) is the physiologically active fraction, although total magnesium (tMg) is often used clinically because a dedicated electrode is required to measure the iMg concentration. The tMg concentration is not correlated with the iMg concentration, especially in severely ill patients. In this report, a case of refractory torsades de pointes (TdP) due to drug-induced long QT syndrome was successfully treated with high-dose magnesium sulfate guided by point-of-care monitoring of the iMg concentration. A woman in her 60s had taken osimertinib for two months to treat lung cancer. TdP occurred after the operation of a thoracic compression fracture under general anesthesia. She was diagnosed with drug-induced long QT syndrome. TdP continued, despite treatment with 6 g magnesium sulfate. The iMg value on the admission to the intensive care unit was 0.92 mmol/L, but TdP occurred intermittently and circulatory dynamics were unstable. After an additional intravenous administration of 1 g magnesium sulfate, continuous intravenous administration was initiated at 1 g/h. TdP terminated when the iMg concentration reached 1.31 mmol/L. Then, the target iMg was set to 1.3 mmol/L. The iMg concentration was measured every two hours to adjust the continuous dose of magnesium sulfate. Magnesium administration was tapered, and she was transferred to a general ward on the third day. She was discharged without complications on the 11th day. Point-of-care monitoring of the iMg concentration and observation of the patient's clinical symptoms were important for the effective and safe treatment of TdP due to drug-induced long QT syndrome.

Open randomized trial of the effects of 6% hydroxyethyl starch 130/0.4/9 and 5% albumin on safety profile, volume efficacy, and glycocalyx degradation in hepatic and pancreatic surgery.

PURPOSE: The aim of this study was to evaluate the effects of hydroxyethyl starch (HES) 130/0.4/9 compared to 5% albumin on renal and coagulation safety profiles, volume efficacy and glycocalyx degradation in major abdominal surgery. METHODS: The study was approved by the institutional ethics committee as a single center, open-labeled randomized trial. Fifty patients undergoing hepatic or pancreatic surgery were randomly assigned to the HES group (n = 25), who received HES 130/0.4/9, or the Albumin group (n = 25), who received 5% albumin. Ringer's acetate solution (3 ml/kg/h) and colloid solution (2 mL/kg/h) were infused and goal-directed fluid management was performed to stabilize hemodynamics. Perioperative changes and differences in serum creatinine, N-acetyl-beta-d-glucosaminidase (NAG), hemodynamics, coagulation parameters and glycocalyx biomarkers were compared between the groups. Blood loss and requirements for transfusion and vasoactive agents were also examined. Statistical analysis was performed by Mann-Whitney U tests, chi-square or Fisher exact test, with P < 0.05 taken to be significant. RESULTS: Serum creatinine levels did not differ between the HES and Albumin groups (median: 0.67 vs. 0.75 mg/dL at anesthesia induction, 0.82 vs. 0.83 mg/dL at ICU admission, 0.67 vs. 0.73 mg/dL one day after surgery, 0.68 vs. 0.70 mg/dL one month after surgery). NAG, coagulation parameters, hemodynamics, glycocalyx biomarkers, intraoperative blood loss, transfusion and use of vasoactive agents did not differ between the groups. CONCLUSION: HES 130/0.4/9 can be used as safely and effectively as 5% albumin. Glycocalyx degradation did not differ between use of these solutions in major abdominal surgery.

[Excessive bleeding in the patients with past history of Hassab's operation].

We report two cases of massive perioperative bleeding and multiple organ failure with past history of Hassab's operation. Massive bleeding occurred during laparotomy and thoracocentesis in each case. After Hassab's operation, collateral circulation and coagulation disorders could develop, and unanticipated massive bleeding might occur. Preparations for excessive bleeding and postoperative intensive care would be required for the patients who have past history of Hassab's operation.

The anticoagulant effect of protamine sulfate is attenuated in the presence of platelets or elevated factor VIII concentrations.

BACKGROUND: Protamine sulfate is the antidote for heparin, but in excess it exerts weak anticoagulation. METHODS: We evaluated the effects of increasing protamine concentrations (0 to 24 microg/mL) on prothrombin time and diluted Russell's viper venom time measurements on thrombin generation in platelet-poor and platelet-rich plasma after activation by tissue factor or actin, and on thromboelastometry in platelet-poor plasma and whole blood from 6 healthy volunteers. The reversibility of excess protamine (24 microg/mL) by recombinant factor VIIa or factor VIII/von Willebrand factor concentrate was also tested. RESULTS: Protamine prolonged prothrombin time and Russell's viper venom time, concentration dependently. Protamine also increased lag time and decreased peak of thrombin generation in platelet-poor plasma after tissue factor and actin activation. In platelet-rich plasma with platelets at 50 to 200 x 10(3)/microL, protamine (24 microg/mL) prolonged the lag time, but had no effect on peak thrombin generation. The addition of factor VIII/von Willebrand factor (1.5-3.0 U/mL) to platelet-poor plasma with protamine (24 microg/mL) decreased lag time and increased peak thrombin generation with actin activation. A therapeutic concentration of recombinant factor VIIa (60 nM) only affected the lag time of thrombin generation triggered with actin. In agreement, protamine increased coagulation time evaluated by thromboelastometry significantly more in platelet-poor plasma than in whole blood. CONCLUSIONS: We demonstrated that protamine affects the propagation of thrombin generation, which is partially reversed by platelets or increased factor VIII/von Willebrand factor concentrations. The present data suggest that excess protamine might potentially increase bleeding in the case of severe thrombocytopenia or low factor VIII.

Fluid therapy with hydroxyethyl starch for massive blood loss during surgery.

PURPOSE: This clinical trial reports the use of hydroxyethyl starch (HES70/0.55/4) at very high dosages during surgery. HES70/0.55/4 has the lowest molecular weight among all HES products, and thus may have the least side effects. This observational retrospective study clarified the effects of high-dose HES70/0.55/4 on coagulation and renal function up to 1 month after massive bleeding during surgery. METHODS: Of 20875 patients on our surgical database, 31 patients were identified who had lost more than 5000 ml of blood during surgery and had survived for more than 1 month. The fluid balance, and pre- and postoperative laboratory data were analyzed. Patients were assessed using acute kidney injury (AKI) criteria. AKI and non-AKI groups were compared regarding volume of HES70/0.55/4 infused and serum creatinine (Cr) levels before surgery and until 1 month after surgery. RESULTS: The mean volumes of blood loss, total transfusions, HES70/0.55/4, and urine output during surgery were 8051 ml; 5765 ml; 3085 ml (54 ml/kg); and 1338 ml (2.7 ml/kg/h), respectively. Cr increased, and activated partial thromboplastin time, prothrombin time and international normalized ratio were prolonged postoperatively (0.77-0.9 mg/dl, 34-52 s, and 1.1-1.7, respectively). Of the 31 patients, 13 developed AKI, and 10 of the 13 had recovered at 1 month. Renal impairment due to HES70/0.55/4 was not evident, as shown by the finding that the HES70/0.55/4 amount infused in the AKI patients (53 ml/kg) did not differ from that in the nonAKI patients (55 ml/kg), and there was no relationship between the amount of HES infused and Cr changes. CONCLUSION: High-dose HES70/0.55/4 could be safely used in massive bleeding during surgery. HES70/0.55/4 may affect coagulation, but renal impairment was not evident 1 month after surgery.

Evaluation of low-dose propofol preadministration to attenuate vascular pain during induction of anesthesia.

STUDY OBJECTIVE: To determine whether a small dose of propofol before induction decreases pain with injection using two different formulas of propofol-10% long-chain triglycerides (LCT) and medium-chain triglycerides (MCT) and LCT. DESIGN: Prospective, randomized, comparative study. SETTING: University-affiliated hospital. PATIENTS: 200 ASA physical status I and II patients. INTERVENTIONS: Group A (LCT control) and group B (MCT/LCT control) were first preadministered normal saline plus Intralipid (Otsuka Pharmaceutical Co, Ltd, Tokyo, Japan) as a placebo, whereas group C (LCT study) and group D (MCT/LCT study) received each formulation of propofol 0.1 mg/kg before induction. After three minutes, groups A and C received LCT propofol two mg/kg for induction. Groups B and D received LCT/MCT propofol in the same manner. MEASUREMENT: Pain was evaluated blindly at the time of both preadministration and induction, using a 4-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. MAIN RESULTS: 36 (72%) LCT and 31 (62%) LCT/MCT control group patients (groups A and B) had pain. Pretreatment with propofol (groups C and D) attenuated the frequency of pain significantly in 21 (42%) and 24 (48%) patients at induction, respectively. CONCLUSION: Long-chain triglyceride and LCT/MCT propofol, 0.1 mg/kg administration before induction, resulted in attenuated pain at an induction dose of propofol.

Gender differences between predicted and measured propofol C(P50) for loss of consciousness.

OBJECTIVE: To investigate gender differences in the effective dose of 50% for loss of consciousness (C(P50LOC)) for propofol using Diprifusor, the most commonly used target-controlled infusion system. DESIGN: Prospective, randomized, comparative study. SETTING: University-affiliated hospital. PATIENTS: 50 ASA physical status I and II patients, aged 20 to 50 years, scheduled for minor surgery. INTERVENTIONS: Patients were randomized into two groups of 25 patients each. A target-controlled infusion of propofol (Diprifusor) was maintained at a predetermined target concentration. After a 10-minute steady state, blinded investigators evaluated patients' consciousness using verbal commands. The propofol test concentration was predetermined using a modified version of Dixon's up-and-down method (starting at 2.5 mug/mL; step size of 0.1 microg/mL). MEASUREMENT: Predicted and measured C(P50LOC) values and bispectral index (BIS) were obtained by averaging the crossover midpoint (ie, consciousness to unconsciousness). Those values were analyzed by unpaired t test: P < 0.05 was considered significant. RESULTS: The predicted C(P50LOC) for men was 2.14 +/- 0.10 microg/mL, which was lower than that for women, 2.55 +/- 0.11 microg/mL (P < 0.0001). No significant difference was found for measured C(P50LOC) in men (2.37 +/- 0.41 microg/mL) and in women (2.30 +/- 0.28 microg/mL) or for BIS measurements. CONCLUSION: Predicted C(P50LOC) by Diprifusor for men tended to be underestimated; that for women tended to be overestimated. Our data support a review of Diprifusor (Astra Zeneca, Osaka, Japan) pharmacokinetic parameters to avoid awareness during operation, particularly for women.

[Newly developed BONFILS Retromolar Intubation Fiberscope for difficult airway].

Battery powered BONFILS Retromolar Intubation Fiberscope (BRIF) is a nonflexible fiberscope having the same curvature as the Macintosh laryngoscope for difficult airway. We used this device in two patients; A 65-year-old man with small chin and a 35-year-old man with neck spinal cord injury. Two trials of orotracheal intubation were accomplished easily in 20 seconds. We conclude that BRIF is useful for orotracheal intubation in patients in whom neck extension is contra-indicated.

Determination of the standard value of circulating blood volume during anesthesia using pulse dye-densitometry: a multicenter study in Japan.

PURPOSE: The standard value for circulating blood volume (BV) during anesthesia was determined by a multicenter study in Japan. The significance of BV on the reduction of blood pressure after the induction of anesthesia was also examined. METHODS: The study included 184 patients from eight university hospitals. After the induction of anesthesia, pulse dye-densitometry was performed according to a uniform protocol. Factors contributing to reduced blood pressure after induction of anesthesia were examined by multiple logistic regression analysis. RESULTS: The mean and standard deviation of BV was 80.0 +/- 13.9 ml x kg(-1); for females and 84.2 +/- 15.3 ml x kg(-1) for males (P > 0.05). There was no age difference in terms of BV. After adjusting for the effects of height, weight, and age, the factors predisposing to a reduction in blood pressure of >20 mmHg after induction of anesthesia were found to be age (P < 0.01) and BV (ml x kg(-1)) (P < 0.001). CONCLUSION: We determined the BV of anesthetized patients before surgery in Japan using pulse dye-densitometry. It is suggested that age is not a factor regarding BV, and that blood pressure tends to be reduced in hypovolemic patients after induction of anesthesia.

[Blood lactate levels during fast-track cardiac anesthesia].

BACKGROUND: Lactate is a very sensitive marker of outcomes in critically ill patients. The aim of this study was to investigate the significance of blood lactate measurement during fast-track cardiac anesthesia. METHODS: We examined arterial blood lactate levels of 12 patients following coronary artery bypass graft surgery under intermittent aortic cross clamping with fast-track cardiac anesthesia. Anesthesia was induced with propofol and fentanyl, and maintained with propofol, fentanyl (total 400-1000 micrograms) and isoflurane. Blood samples were collected from a radical artery catheter. RESULTS: At the termination of the extracorporeal circulation, the blood lactate was 10.3 +/- 2.0 (7.4-12.5) mmol.l-1. This value decreased slowly to 1.5 +/- 0.4 mmol.l-1 on the second postoperative day. All patients were extubated within 4 hours after surgery. Vital signs were stable, and no cardiac events occurred perioperatively. CONCLUSIONS: A continuous decline in blood lactate levels was related to a favorable postoperative course. Further research might be required to prevent transient hyperlactecemia at the end of cardiopulmonary bypass.