Decrease in hemoglobin level predicts increased risk for severe respiratory failure in COVID-19 patients with pneumonia.

BACKGROUND: In December 2019, the coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), emerged in Wuhan, China, and has since spread throughout the world. This study aimed to investigate the association between the change in laboratory markers during the three days after pneumonia diagnosis and severe respiratory failure in COVID-19 patients. METHODS: Data of 23 COVID-19 patients with pneumonia, admitted to the Kumamoto City Hospital between February and April 2020 were retrospectively analyzed. RESULTS: Among the 23 patients, eight patients received mechanical ventilation (MV) (MV group), and the remaining 15 comprised the non-MV group. The levels of hemoglobin (Hb) and albumin (Alb) decreased in the MV group during the three days after pneumonia diagnosis more than in the non-MV group (median Hb: 1.40 vs. -0.10 g/dL, P = 0.015; median Alb: 0.85 vs. -0.30 g/dL, P = 0.020). Univariate logistic regression analysis showed that the decrease in Hb was associated with receiving MV care (odds ratio: 0.313, 95% confidence interval: 0.100-0.976, P = 0.045). Receiver operating characteristic curve analyses showed that the optimal cut-off value for the decrease in Hb level was -1.25 g/dL, with sensitivity and specificity values of 0.867 and 0.750, respectively. CONCLUSIONS: The decrease in Hb level during the short period after pneumonia diagnosis might be a predictor of worsening pneumonia in COVID-19 patients.

[Case of tracheal agenesis found during surgery].

We reported a case of tracheal agenesis (TA) that was diagnosed during surgery. A female infant, weighing 1,104 g, was born at the 29 weeks of gestation. She showed severe respiratory distress without crying. Oxygenation was improved by mask ventilation, but tracheal intubation was very difficult. Tracheoesophageal fistula (TEF) was suspected because significant amount of air from nasogastric tube was noticed. Physical examination and X-ray findings suggested Gross E type TEF, duodenal atresia and cloaca. On the second day of life, ligation of TEE gastrostomy and colostomy were scheduled. Although operation was started without problems, ventilation became impossible when TEF was clamped and release of clamping made it possible. Bronchoscopic investigation revealed that tracheal tube was located in the esophagus. We have never doubted the esophageal intubation, because patient was ventilated preoperatively and signs of respiratory distress syndrome were successfully treated by the surfactant replacement therapy through tracheal tube. Type II TA according to Floyd's classification was diagnosed by bronchoscopic and echographic investigations. Distal esophageal ligation, gastrostomy and esophagostomy were performed. She died on the 12th day of life in spite of vigorous ventilatory and cardiovascular support.

[Anesthesia for cesarean section in a patient with transient diabetes insipidus].

A 32-year-old pregnant female was admitted to our hospital at 32 week gestation and was scheduled for emergent cesarean section because of fetal distress. She had been suffering hydrodipsia and dry mouth, and had lost 4 kg in 2 weeks. Hypernatremia, hyperchloremia, and lower urinary specific gravity were preoperatively noted. Her electrolyte imbalance was partially corrected by the infusion of 1400 ml of 5% glucose solution and 500 ml of acetated Ringer's solution, but unexpected hyperglycemia; 440 mg.dl-1, appeared before surgery. Cesarean section was successfully performed with spinal anesthesia. A 1566 g male infant was delivered with 1 and 5 min Apgar scores of 2 and 1. Hyperglycemia and secondary hypoglycemia occurred in the infant in the neonatal ICU. The mother's fluid loss, including blood and amniotic fluid, was estimated at 784 ml. Five hundred milliliters of acetated Ringer's solution and 1000 ml of half saline solution with 2.5% glucose were infused before delivery, followed by the glucose solution containing a low concentration of sodium after delivery. After surgery, high serum osmotic pressure and paradoxically low urinary osmotic pressure were found. The plasma antidiuretic hormone level was normal against the high serum osmotic pressure. The electrolyte imbalance and urinary osmotic pressure were improved by using I-deamino-8-d-arginine vasopressin, and DI was finally diagnosed. Hormonal therapy was discontinued on day 20, and the patient was discharged on day 21. Some pregnancies are complicated by transient DI. Anesthesiologists have to consider DI when a pregnant female has symptoms of dehydration and a significant electrolyte imbalance.

[Propofol was useful for intractable convulsion in a patient with tetanus: a case report].

An 82-year-old woman with severe tetanus was admitted to our ICU. Anti-convulsive treatment was started by continuous intravenous administration of midazolam followed by thiamylal. On day 15, thiamylal became insufficient to manage the spastic convulsion without frequent intravenous administration of other sedative and muscle relaxants. On day 16, intravenous infusion of propofol was started at the rate of 1 mg.kg-1.h-1. Propofol was more effective than thiamylal to treat convulsion and to stabilize the sympathetic nerve activity. Propofol was also effective to achieve the better general condition in which enteral nutrition could be started. In this case, propofol was apparently more suitable than thiamylal to manage a patient with tetanic convulsion.