The Japanese Epidemiologic Study for Perioperative Anaphylaxis, a prospective nationwide study: allergen exposure, epidemiology, and diagnosis of anaphylaxis during general anaesthesia.

BACKGROUND: Diagnosis of perioperative anaphylaxis is often challenging. This study describes the utility of a newly developed tool for identifying patients with a high possibility of anaphylaxis, and aimed to investigate the frequency of anaphylaxis with each drug during the perioperative period in Japan. METHODS: This study included patients with anaphylaxis of Grade 2 or higher severity during general anaesthesia at 42 facilities across Japan in 2019 and 2020. We developed and adopted a unique objective evaluation tool yielding a composite score for diagnosing anaphylaxis, which includes the results of skin tests and basophil activation tests, and clinical scores for perioperative anaphylaxis. The number of cases using each drug and the total number of anaphylaxis cases were investigated to calculate the frequency of anaphylaxis. RESULTS: General anaesthesia was performed in 218 936 cases, which included 55 patients with suspected perioperative anaphylaxis. The developed composite score diagnosed 43 of them with a high probability of anaphylaxis. The causative agent was identified in 32 cases. Plasma histamine levels showed high diagnostic accuracy for anaphylaxis. The top causative agents were rocuronium (10 cases in 210 852 patients, 0.005%), sugammadex (7 cases in 150 629 patients, 0.005%), and cefazolin (7 cases in 106 005 patients, 0.007%). CONCLUSIONS: We developed a composite tool to diagnose anaphylaxis, and found that the combination of tryptase levels, skin testing, and basophil activation testing results and clinical score improved the certainty of anaphylaxis diagnosis. The incidence of perioperative anaphylaxis in our study was 1 in about 5000 general anaesthesia cases. CLINICAL TRIAL REGISTRATION: UMIN000035350.

Effects of Thoracic Epidural Anesthesia on Systemic and Local Inflammatory Responses in Patients Undergoing Lung Cancer Surgery: A Randomized Controlled Trial.

OBJECTIVE: Inflammatory responses play major roles in the development of acute lung injury following lung cancer surgery. The authors tested the hypothesis that thoracic epidural anesthesia (TEA) during surgery could attenuate both systemic and local inflammatory cytokine productions in patients undergoing lung cancer surgery. DESIGN: A prospective randomized controlled trial. SETTING: At Keio University Hospital, Tokyo, Japan. PARTICIPANTS: Patients scheduled for lung cancer surgery. INTERVENTIONS: Sixty patients were randomly allocated into two groups (n = 30 each group): the epidural group (group E), in which anesthesia was maintained with propofol, fentanyl, rocuronium, and epidural anesthesia with 0.25% levobupivacaine; or the remifentanil group (group R), in which a remifentanil infusion was used as a potent analgesia instead of epidural anesthesia. MEASUREMENTS AND MAIN RESULTS: The lung epithelial lining fluid (ELF) and blood sampling were collected prior to one-lung ventilation (OLV) initiation (T1) and at 30 minutes after the end of OLV (T2). The concentrations of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-10 in the ELF at T2 were increased significantly compared with those at T1 in both groups. The ELF concentration of IL-6 in group E was significantly lower than that in group R at T2 (median [interquartile range]: 39.7 [13.8-80.2] versus 76.1 [44.9-138.2], p = 0.008). Plasma IL-6 concentrations at T2, which increased in comparison to that at T1, were not significantly different between the two groups. The plasma concentrations of TNF-α did not change in both groups. CONCLUSIONS: This randomized clinical trial suggested that TEA could attenuate local inflammatory responses in the lungs during lung cancer surgery.

Life-threatening rocuronium-induced anaphylactic shock without cutaneous manifestations successfully reversed with sugammadex: a case report.

BACKGROUND: Recognition of rocuronium-induced anaphylaxis is often challenging, owing to its diverse clinical manifestations. Regarding treatment, several reports have described the efficacy of sugammadex, while conflicting reports have also been published. CASE: A 71-year-old man was scheduled to undergo split-thickness skin grafting surgery on his hip. During the induction of general anesthesia, the patient developed profound circulatory collapse without any cutaneous manifestations, which required 40 min of cardiopulmonary resuscitation. Later, the patient developed circulatory collapse again during the induction of anesthesia for tracheostomy surgery, which apparently coincided with the administration of rocuronium. Rocuronium-induced anaphylactic shock was suspected, and the administration of sugammadex resulted in swift recovery of hemodynamics. The basophil activation test revealed a positive reaction to rocuronium. CONCLUSION: The possibility of rocuronium-induced anaphylaxis should be considered when the circulatory collapse coincides with rocuronium administration, even though cutaneous manifestation is absent. Sugammadex can be a treatment option in such atypical cases.

Retraction Note: Desflurane anesthesia worsens emergence agitation in adult patients undergoing thyroid surgery compared to sevoflurane anesthesia.

The Editor-in-Chief has retracted this article [1]. The ethics committee approval was granted for an observational study and the need for patient consent was waived. However, the study design described is a randomized controlled trial and therefore patient consent should have been obtained. All authors agree with this retraction.

Ringer's ethyl pyruvate solution attenuates hypoperfusion and renal injury after multivisceral ischemia-reperfusion in rabbits.

Ringer's ethyl pyruvate solution (REPS) has been protective against experimental renal, intestinal, and spinal ischemia and may be useful for organ protection in major vascular surgery. The purpose of this study was to investigate whether REPS attenuates organ injury in a rabbit model of supraceliac aortic cross-clamp that simulates thoracoabdominal aortic surgery. Following the Institutional Animal Care and Use Committee's approval, 20 rabbits were undergone cross-clamping of the supraceliac thoracic aorta for 30 min, and observed for 180 min after reperfusion. Either REPS (33 mg/kg/h of ethyl pyruvate) or Ringer's lactate solution were infused throughout the study period. Arterial pressure and aortic blood flow were continuously monitored. Blood lactate concentration, serum transaminase levels, neutrophil activation, and urinary N-acetyl-beta-glucosaminidase (NAG) activity were evaluated. After reperfusion, supraceliac aortic blood flow was significantly higher, and urinary NAG was significantly lower in animals that received REPS, while the other parameters were not significantly different. In conclusion, REPS attenuated the reduction of aortic blood flow and urinary NAG elevation after the cross-clamp of supraceliac aorta.

Evaluation of the Safety of Percutaneous Dilational Tracheostomy Compared with Surgical Tracheostomy in the Intensive Care Unit.

BACKGROUND: Tracheostomy is a necessary procedure for patients who require long-term mechanical ventilation support. There are two methods for tracheostomy in current use: surgical tracheostomy (ST) and percutaneous dilational tracheostomy (PDT). In the current study, we retrospectively compared the safety of both procedures performed in our intensive care unit (ICU). METHODS: In this study, we enrolled subjects who underwent tracheostomy in our ICU between January 2012 and March 2016. We excluded subjects who were <20 years old and underwent tracheostomy in the operating room. As a primary outcome, we evaluated the rate of complications between ST and PDT groups. The length of ICU stay, time to tracheostomy from intubation, and the rate of mechanical ventilation and mortality at 28 postoperative days were also examined as secondary outcomes. RESULTS: Compared with the ST group, the rate of all complications was lower in the PDT group (13.4% vs. 38.8%, p=0.007). Although the rate of intraoperative complications did not differ between the two groups (3.8% vs. 8.1%, p=0.62), relative to the ST procedure, the PDT procedure was associated with fewer postoperative complications (34.6% vs. 9.6%, p=0.003). Among postoperative complications, accidental removal of the tracheostomy tube and an air leak from the tracheostomy fistula were less frequent in the PDT group than the ST group. Between the two groups, there were no significant differences in their secondary outcomes. CONCLUSION: This retrospective study indicates that relative to ST, PDT is a safer procedure to be performed in the ICU. Fewer postoperative complications following PDT might be attributed to the small skin incision made during this procedure.

Beta-Blocker Therapy Preserves Normal Splenic T-Lymphocyte Numbers Reduced in Proportion to Sepsis Severity in a Sepsis Model.

Lymphocyte cell death contributes to sepsis-induced immunosuppression, leading to poor prognosis. This study examined whether sepsis severity and beta-blocker therapy could affect the degree of T-lymphocyte cell death in a mouse model of sepsis. In the first control study, 20 animals were allocated to 4 groups: control group with sham operation (group C, n = 5) and 3 groups with cecum ligation and puncture (CLP) performed at 3 different sites: proximal, middle, and distal cecum (groups CLP-P, CLP-M, and CLP-D, respectively; n = 5 in each group). Their spleens were resected under general anesthesia 24 hours after CLP, and the total number of normal splenic T lymphocytes per mouse and the percentage of apoptotic T lymphocytes were evaluated using flow cytometry. In the second experimental study, the effect of the beta-blocker esmolol was examined in CLP-P (group CLP-PE vs. CLP-P; n = 5 in each group). The total normal splenic T-lymphocyte numbers per mouse significantly decreased in proportion to CLP severity (group C, 18.6 × 106 (15 × 106-23.6 × 106); CLP-D, 9.2 × 106 (8.8 × 106-9.8 × 106); CLP-M, 6.7 × 106 (6.3 × 106-7.0 × 106); and CLP-P, 5.3 × 106 (5.1 × 106-6.8 × 106)). Beta-blocker therapy restored T-lymphocyte numbers (group CLP-PE vs. CLP-P; 6.94 ± 1.52 × 106 vs. 4.18 ± 1.71 × 106; p=0.027) without affecting apoptosis percentage. Beta-blocker therapy might improve sepsis-induced immunosuppression via normal splenic T-lymphocyte preservation.

Aberrant resting-state functional connectivity of the dorsolateral prefrontal cortex to the anterior insula and its association with fear avoidance belief in chronic neck pain patients.

Chronic neck pain (CNP), a global health problem, involves a large amount of psychological and socioeconomic burdens. Not only physical causes but also behavioral disorders such as a fear-avoidance belief (FAB) can associate with the chronicity of neck pain. However, functional brain mechanisms underlying CNP and its related behavioral disorders remain unknown. The aim of the current resting-state functional magnetic resonance imaging (fMRI) study was to explore how the functional brain networks differed between CNP patients and age- and sex-matched healthy, pain-free controls (HCs). We also investigated whether these possible brain network changes in CNP patients were associated with fear avoidance belief (FAB) and the intensity of pain. We analyzed the resting-state fMRI data of 20 CNP patients and 20 HCs. FAB and the intensity of pain were assessed by Tampa Scale for Kinesiophobia (TSK) and Visual Analog Scale (VAS) of pain. The whole brain analysis showed that CNP patients had significant different functional connectivity (FC) compared with HCs, and the right dorsolateral prefrontal cortex (DLPFC) was a core hub of these altered functional networks. Furthermore, general linear model analyses showed that, in CNP patients, the increased FC between the right DLPFC and the right anterior insular cortex (aIC) significantly associated with increased TSK (p = 0.01, statistical significance after Bonferroni correction: p<0.025), and the FC between the right DLPFC and dorsal posterior cingulate cortex had a trend of inverse association with VAS (p = 0.04). Our findings suggest that aberrant FCs between the right DLPFC and aIC associated with CNP and its related FAB.

Automated Assessment of Existing Patient's Revised Cardiac Risk Index Using Algorithmic Software.

BACKGROUND: Previous work in the field of medical informatics has shown that rules-based algorithms can be created to identify patients with various medical conditions; however, these techniques have not been compared to actual clinician notes nor has the ability to predict complications been tested. We hypothesize that a rules-based algorithm can successfully identify patients with the diseases in the Revised Cardiac Risk Index (RCRI). METHODS: Patients undergoing surgery at the University of California, Los Angeles Health System between April 1, 2013 and July 1, 2016 and who had at least 2 previous office visits were included. For each disease in the RCRI except renal failure-congestive heart failure, ischemic heart disease, cerebrovascular disease, and diabetes mellitus-diagnosis algorithms were created based on diagnostic and standard clinical treatment criteria. For each disease state, the prevalence of the disease as determined by the algorithm, International Classification of Disease (ICD) code, and anesthesiologist's preoperative note were determined. Additionally, 400 American Society of Anesthesiologists classes III and IV cases were randomly chosen for manual review by an anesthesiologist. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve were determined using the manual review as a gold standard. Last, the ability of the RCRI as calculated by each of the methods to predict in-hospital mortality was determined, and the time necessary to run the algorithms was calculated. RESULTS: A total of 64,151 patients met inclusion criteria for the study. In general, the incidence of definite or likely disease determined by the algorithms was higher than that detected by the anesthesiologist. Additionally, in all disease states, the prevalence of disease was always lowest for the ICD codes, followed by the preoperative note, followed by the algorithms. In the subset of patients for whom the records were manually reviewed, the algorithms were generally the most sensitive and the ICD codes the most specific. When computing the modified RCRI using each of the methods, the modified RCRI from the algorithms predicted in-hospital mortality with an area under the receiver operating characteristic curve of 0.70 (0.67-0.73), which compared to 0.70 (0.67-0.72) for ICD codes and 0.64 (0.61-0.67) for the preoperative note. On average, the algorithms took 12.64 ± 1.20 minutes to run on 1.4 million patients. CONCLUSIONS: Rules-based algorithms for disease in the RCRI can be created that perform with a similar discriminative ability as compared to physician notes and ICD codes but with significantly increased economies of scale.

Cesarean hysterectomy in a hybrid operating room for placenta percreta: a report of three cases.

BACKGROUND: Placenta percreta is the most severe abnormality in invasive placenta and often treated with cesarean hysterectomy. Endovascular embolization for placental abnormality is known to reduce bleeding from the placental bed and from the abnormal neovasculature surrounding the uterus. We describe three cases of placenta percreta treated with uninterrupted cesarean hysterectomy and embolization performed using a hybrid operating room (HOR). CASE DESCRIPTION: Cases were two placenta previa percretas and an impending uterine rupture with placenta percreta, treated with elective cesarean hysterectomy in HOR. Planned conversion of spinal to general anesthesia was performed after the fetal delivery. Immediate embolic devascularization of abnormal neovasculature was directly observed and facilitated adhesiolysis. Surgical blood losses were 1850 g, 2500 g, and 1180 g, respectively. CONCLUSION: Cesarean hysterectomy combined with endovascular embolization in the HOR for placenta percreta is an advantageous option to enhance patient safety by multidisciplinary approach without patient transfer.

Cardiac output and stroke volume variation measured by the pulse wave transit time method: a comparison with an arterial pressure-based cardiac output system.

Hemodynamic monitoring is mandatory for perioperative management of cardiac surgery. Recently, the estimated continuous cardiac output (esCCO) system, which can monitor cardiac output (CO) non-invasively based on pulse wave transit time, has been developed. Patients who underwent cardiovascular surgeries with hemodynamics monitoring using arterial pressure-based CO (APCO) were eligible for this study. Hemodynamic monitoring using esCCO and APCO was initiated immediately after intensive care unit admission. CO values measured using esCCO and APCO were collected every 6 h, and stroke volume variation (SVV) data were obtained every hour while patients were mechanically ventilated. Correlation and Bland-Altman analyses were used to compare APCO and esCCO. Welch's analysis of variance, and four-quadrant plot and polar plot analyses were performed to evaluate the effect of time course, and the trending ability. A p-value < 0.05 was considered statistically significant. Twenty-one patients were included in this study, and 143 and 146 datasets for CO and SVV measurement were analyzed. Regarding CO, the correlation analysis showed that APCO and esCCO were significantly correlated (r = 0.62), and the bias ± precision and percentage error were 0.14 ± 1.94 (L/min) and 69%, respectively. The correlation coefficient, bias ± precision, and percentage error for SVV evaluation were 0.4, - 3.79 ± 5.08, and 99%, respectively. The time course had no effects on the biases between CO and SVV. Concordance rates were 80.3 and 75.7% respectively. While CO measurement with esCCO can be a reliable monitor after cardiovascular surgeries, SVV measurement with esCCO may require further improvement.

Improving Perioperative Outcomes Through Minimally Invasive and Non-invasive Hemodynamic Monitoring Techniques.

An increasing number of patients require precise intraoperative hemodynamic monitoring due to aging and comorbidities. To prevent undesirable outcomes from intraoperative hypotension or hypoperfusion, appropriate threshold settings are required. These setting can vary widely from patient to patient. Goal-directed therapy techniques allow for flow monitoring as the standard for perioperative fluid management. Based on the concept of personalized medicine, individual assessment and treatment are more advantageous than conventional or uniform interventions. The recent development of minimally and noninvasive monitoring devices make it possible to apply detailed control, tracking, and observation of broad patient populations, all while reducing adverse complications. In this manuscript, we review the monitoring features of each device, together with possible advantages and disadvantages of their use in optimizing patient hemodynamic management.

Interaction between anesthetic conditioning and ischemic preconditioning on metabolic function after hepatic ischemia-reperfusion in rabbits.

BACKGROUND: Both anesthetic-induced and ischemic preconditioning are protective against hepatic ischemia-reperfusion injury. However, the effects of these preventive methods on the metabolic function remain to be elucidated. We investigated the anesthetic conditioning and ischemic preconditioning on the metabolic function of the rabbit model of hepatic ischemia-reperfusion. METHODS: After approval by the institutional animal care and use committee, 36 Japanese White rabbits underwent partial hepatic ischemia for 90 min either under sevoflurane or propofol anesthesia. All the rabbits underwent 90 min of hepatic ischemia, and half of the rabbits in each group underwent additional 10-min ischemia and 10-min reperfusion before index ischemia. Hepatic microvascular blood flow was intermittently measured during reperfusion period, and galactose clearance, serum aminotransferase activities, and lactate concentrations were determined 180 min after reperfusion. RESULTS: Neither anesthetic conditioning with sevoflurane nor ischemic preconditioning altered hepatic microvascular blood flow during reperfusion and serum transaminase activities after reperfusion. However, galactose clearance of reperfused liver was significantly higher under sevoflurane anesthesia than propofol (0.016 ± 0.005/min vs. 0.011 ± 0.004/min). Statistically significant interaction between anesthetic choice and application of ischemic preconditioning suggests that the ischemic preconditioning is selectively protective under propofol anesthesia. Increase of blood lactate concentration was significantly suppressed under sevoflurane anesthesia compared to propofol (1.5 ± 0.8 vs. 3.9 ± 1.4 mmol/l) without any statistically significant interaction with the application of ischemic preconditioning. CONCLUSION: Sevoflurane attenuated the decrease of galactose clearance and increase of the blood lactate after reperfusion compared to propofol. Application of ischemic preconditioning was significantly protective under propofol anesthesia.

Anaphylactic Reactions to Native and Light-Exposed Sugammadex Suggested by Basophil Activation Test: A Report of 2 Cases.

We describe 2 patients who developed anaphylactic shock after sugammadex administration during anesthesia. Both had no history of prior sugammadex administration. The serum tryptase concentrations were elevated after the allergic reaction. Basophil activation testing 1 month after the events was positive for sugammadex in 1 patient, and negative in the other. However, it was positive for light-exposed sugammadex solution in both patients, suggesting a possible allergic reaction to a denatured compound of sugammadex generated by light exposure of the sugammadex solution.

Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study.

BACKGROUND: The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols that promote opioid-free and multimodal analgesia. The objective of this study was to assess the impact of an ERAS intervention for colorectal surgery on discharge opioid prescribing practices. METHODS: We conducted a historical-prospective quality improvement study of an ERAS protocol implemented for patients undergoing colorectal surgery with a focus on the opioid-free and multimodal analgesia components of the pathway. We compared patients undergoing colorectal surgery 1 year before implementation (June 15, 2015, to June 14, 2016) and 1 year after implementation (June 15, 2016, to June 14, 2017). RESULTS: Before the ERAS intervention, opioids at discharge were not significantly increasing (1% per month; 95% confidence interval [CI], -1% to 3%; P = .199). Immediately after the ERAS intervention, opioid prescriptions were not significantly lower (13%; 95% CI, -30% to 3%; P = .110). After the intervention, the rate of opioid prescriptions at discharge did not decrease significantly 1% (95% CI, -3% to 1%) compared to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%-83%). CONCLUSIONS: This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid-free anesthesia and multimodal analgesia, we did not observe an impact on discharge opioid prescribing practices. The majority of patients were discharged with an opioid prescription, including those with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge. This observation in the setting of an ERAS pathway that promotes multimodal analgesia suggests that our findings are very likely to also be observed in non-ERAS settings and offers an opportunity to modify opioid prescribing practices on discharge after surgery. For opioid-free anesthesia and multimodal analgesia to influence the opioid epidemic, the dose and quantity of the opioids prescribed should be modified based on the information gathered by in-hospital pain scores and opioid use as well as pain history before admission.

Desflurane anesthesia worsens emergence agitation in adult patients undergoing thyroid surgery compared to sevoflurane anesthesia.

BACKGROUND: The effect of volatile anesthetics on emergence agitation in adults remains unclear. We compared the degree of emergence agitation between desflurane and sevoflurane anesthesia in adults undergoing thyroid surgery. FINDINGS: One hundred and sixteen patients with American Society of Anesthesiologists status 1 or 2 were randomized into two groups: the desflurane group (group D) and the sevoflurane group (group S). After induction of anesthesia with fentanyl (1-2 µg/kg) and propofol (1.5-2.5 mg/kg), tracheal intubation was facilitated with suxamethonium (0.5-1.0 mg/kg). In group D, anesthesia was maintained with desflurane in 66% nitrous oxide and 33% oxygen supplemented with fentanyl when necessary; in group S, sevoflurane was used instead of desflurane. After the end of the surgery, emergence agitation was evaluated with a modified pediatric anesthesia emergence delirium scale (ranging from 0 to 16, with higher scores indicating more severe emergence agitation) before extubation. Time to extubation from the end of the surgery, postoperative pain (evaluated by a numerical rating scale [NRS]), and postoperative nausea and vomiting (PONV) after surgery were examined. The degree of emergence agitation was more severe in group D than in group S (median [interquartile range]: 5 [4-7] vs 4 [2-6], p = 0.008). Time to extubation, NRS scores, and PONV rates were similar between the two groups. CONCLUSIONS: Desflurane anesthesia worsened emergence agitation as compared with sevoflurane in adult patients undergoing thyroid surgery, but did not affect time to extubation, postoperative pain, or PONV. TRIAL REGISTRATION: UMIN000014215.

Neutrophil gelatinase-associated lipocalin regulates gut microbiota of mice.

BACKGROUND AND AIM: Because neutrophil gelatinase-associated lipocalin (NGAL) is known to provide significant bacteriostatic effects during infectious conditions, we tested the hypothesis that this protein is up-regulated and secreted into the intraluminal cavity of the gut under critically ill conditions and is thus responsible for the regulation of bacterial overgrowth. METHODS: With our institutional approval, male C57BL/6J mouse (6-7 weeks) were enrolled and applied for lipopolysaccharide or peritonitis model compared with naïve control. We assessed NGAL protein concentrations in intestinal lumen and up-regulation of NGAL expression in intestinal tissues in in vivo as well as ex vivo settings. Simultaneously, we examined the effects of NGAL protein administration on the growth of Escherichia coli (E. coli) in in vivo and in vitro experimental settings. The localization of NGAL in intestinal tissues and lumen was also assessed by immunohistological approach using NGAL antibody. RESULTS: Both lipopolysaccharide and peritonitis insults evoked the marked up-regulation of NGAL mRNA and protein levels in gut tissues such as crypt cells. In addition, the administration of NGAL protein significantly inhibited the outgrowth of enteric E. coli under both in vitro and in vivo conditions, accompanied by histological evidence. CONCLUSION: Neutrophil gelatinase-associated lipocalin protein accompanied by apparent bacteriostatic action accumulated in the intestinal wall and streamed into the mucosal layer during critically ill state, thereby possibly shaping microbiota homeostasis in the gut.

[Difficult Perioperative Glucose Management in a Type 2 Diabetic Patient with Anti-insulin Antibody Undergoing Laparoscopic Partial Liver Resection].

A 50-year-old man with type 2 diabetes mellitus was scheduled for laparoscopic partial liver resection. Six months prior to the surgery, he developed frequent hypoglycemic attacks and was diagnosed as anti-insulin antibody positive. The operation was performed under general anesthesia with epidural anesthesia. Intermit- tent and continuous insulin administration was required during liver resection due to persistent hyperglycemia. After termination of the liver resection, the patient exhibited uncontrolled hypo- and hypergly- cemia, and recovery from anesthesia was delayed due to severe hypoglycemia. He recovered immediately after 40% glucose administration. However, frequent glucose administration was required for two hours after transfer to the ICU due to hypoglycemia. It should be born in mind that preoperative poor glucose control might be caused by anti-insulin antibodies and lead to difficult perioperative glucose management.