An autopsy case of a young man with a single overdose of dextromethorphan.

Dextromethorphan (DXM) is an over-the-counter antitussive that is commonly used worldwide. Recently, DXM has become popular among young individuals because of its euphoric, hallucinogenic, and dissociative properties. Despite an increasing number of patients with DXM addiction, fatal cases of DXM poisoning are rare, and patients with fatalities often ingest DXM along with other drugs. Here, we report an autopsy case in which DXM was detected without multidrug ingestion. A man in his early twenties was found dead at home; no external injuries or obvious internal lesions were found during the autopsy. The toxicological analyses revealed extremely high concentrations of DXM, and no drugs other than DXM were detected. To the best of our knowledge, this is the first case report to describe a death caused by a single overdose of DXM in Japan. Public awareness regarding the risks associated with a massive ingestion of DXM should be increased.

Cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic aortic repair.

BACKGROUND: Cerebrospinal fluid drainage (CSFD) is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair. Although small studies support the use of CSFD, systematic reviews have not suggested definite conclusion and a large-scale study is needed. Therefore, we reviewed medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open and endovascular repair) at multiple institutions to assess the association between CSFD and postoperative motor deficits. METHODS: Patients included in this study underwent descending or thoracoabdominal aortic repair between 2000 and 2013 at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery. We conducted a retrospective study to investigate whether motor-evoked potential monitoring is effective in reducing motor deficits in thoracic aortic aneurysm repair. We use the same dataset to examine whether CSFD reduces motor deficits after propensity score matching. RESULTS: We reviewed data from 1214 patients [open surgery, 601 (49.5%); endovascular repair, 613 (50.5%)]. CSFD was performed in 417 patients and not performed in the remaining 797 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. After propensity score matching (n = 700), mixed-effects logistic regression performed revealed that CSFD is associated with postoperative motor deficits at discharge [adjusted odds ratio (OR), 3.87; 95% confidence interval (CI), 2.30-6.51]. CONCLUSION: CSFD may not be effective for postoperative motor deficits at discharge.

Clinical Utility of Intraoperative Motor-Evoked Potential Monitoring to Prevent Postoperative Spinal Cord Injury in Thoracic and Thoracoabdominal Aneurysm Repair: An Audit of the Japanese Association of Spinal Cord Protection in Aortic Surgery Database.

BACKGROUND: Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits. METHODS: Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated whether intraoperative MEP monitoring was associated with postoperative motor deficits at discharge after open and endovascular aortic repair. RESULTS: We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge did not have a significant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69-1.88; P = .624), but with other factors: history of neural deficits (adjusted OR, 6.08; 95% CI, 3.10-11.91; P < .001), spinal drainage (adjusted OR, 2.14; 95% CI, 1.32-3.47; P = .002), and endovascular procedure (adjusted OR, 0.45; 95% CI, 0.27-0.76; P = .003). The sensitivity and specificity of MEP <25% of control value for motor deficits at discharge were 37.8% (95% CI, 26.5%-49.5%) and 95.5% (95% CI, 94.7%-96.4%), respectively. CONCLUSIONS: MEP monitoring was not significantly associated with motor deficits at discharge.

Asymptomatic and symptomatic postoperative visual dysfunction after cardiovascular surgery with cardiopulmonary bypass: a small-sized prospective observational study.

OBJECTIVE: Postoperative visual dysfunction (POVD) after cardiovascular surgery rarely is reported, since it is more likely underdetected and underreported. This study was designed to verify the presence of POVD, including a variety of asymptomatic as well as symptomatic visual dysfunctions after cardiovascular surgery with cardiopulmonary bypass (CPB). DESIGN: A prospective observational study. SETTING: Cardiothoracic surgery in a medical university hospital. PARTICIPANTS: Seventy-one patients undergoing elective cardiovascular surgery with CPB. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were assessed by a battery of 7 neuro-ophthalmic examinations preoperatively and postoperatively, including fundus, visual field, eye movement, color vision, visual acuity, intraocular pressure, and critical flicker frequency. Patients were considered to have POVD if they had postoperative new abnormal findings of neuro-ophthalmic examinations. One patient was excluded due to a failure of postoperative neuro-ophthalmic examinations. In 16 of 70 patients analyzed in this study, selective cerebral perfusion was required for aortic arch surgery. Of 70 patients, a total of 8 patients (11.4%) had postoperative new abnormal findings in neuro-ophthalmic examinations, including new visual field deficits in 4, reduced visual acuity in 4, and/or increased intraocular pressure in 1 patient. Of these 8 patients, symptomatic POVD was recognized in 1 patient (1.4%) with postoperative visual field deficit and reduced visual acuity. There were no new abnormal findings compared with preoperative results in postoperative funduscopy, eye movement, color vision, and critical flicker frequency. CONCLUSIONS: These results indicated that the asymptomatic as well as symptomatic POVD can develop after cardiovascular surgery with CPB, and their incidence may be relatively high.

[Perioperative fibrinogen concentrations in cardiac surgery with cardiopulmonary bypass].

BACKGROUND: Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) need many blood products due to deficiency of coagulation factors. Blood transfusion therapy in patients with excessive bleeding after CPB is generally empiric. We checked and studied the fibrinogen concentration and transfusion, as well as bleeding amount in the perioperative period. METHODS: The study was approved by our institutional ethics committee. Thirty patients were studied. Blood samples were obtained at the induction of anesthesia (before CPB), at the end of CPB, at the end of operation, and on the next morning, or before the patient was given fresh frozen plasma in the intensive care unit. RESULTS: For all cases, fibrinogen concentration and platelet concentration were lowest at the end of CPB. Fibrinogen concentration rose up to before CPB level on the next morning. The group in which fibrinogen concentration was less than 150 mg x dl(-1) at the end of CPB consumed more blood products than the group with fibrinogen concentration of over 150 mg x dl(-1). CONCLUSIONS: Blood transfusion therapy based on fibrinogen concentration is needed to maintain adequacy of the perioperative blood transfusion and blood conservation in cardiac surgery.

Changes in intraocular pressure during prone spine surgery under propofol and sevoflurane anesthesia.

BACKGROUND: Intraocular pressure (IOP) has been shown to increase during prone spine surgery. Although propofol and sevoflurane have been widely used during such surgery, there have been no data to compare the IOP changes under propofol and sevoflurane anesthesia. The present study was therefore conducted to investigate IOP changes under propofol and sevoflurane anesthesia during prone spine surgery. METHOD: After institutional approval and informed consent, 24 patients undergoing prone spine surgery were studied. Patients were randomly allocated to 1 of 2 groups: the propofol or sevoflurane group. Propofol or sevoflurane was administered to maintain the bispectral index between 40 and 60. The IOP was measured using a Tonopen XL hand-held tonometer 10 minutes after induction of anesthesia in the supine position (baseline), 10, 60, and 120 minutes after positioning in the prone position, and 10 minutes after returning to the supine position. RESULTS: There were no significant differences in IOP values at baseline between the 2 groups. IOP values after positioning in the prone position were significantly higher than those at baseline in both groups (propofol group: from 8.9±3.5 to 21.9±5.0 mm Hg; sevoflurane group: from 11.6±3.9 to 24.8±3.4 mm Hg; P<0.05). Although IOP values were higher in the sevoflurane group than in the propofol group, the differences in IOP values were not statistically significant. CONCLUSIONS: The results indicated that the choice of anesthetic agent, sevoflurane or propofol, did not have significant effects on IOP changes during a relatively short interval of prone spine surgery.

Changes in intraocular pressure during cardiac surgery with and without cardiopulmonary bypass.

PURPOSE: Data on intraocular pressure (IOP) during cardiac surgery with cardiopulmonary bypass (CPB) and anesthetic management are limited. This study was conducted to investigate changes in IOP during cardiac surgery with and without CPB. METHODS: IOP was intraoperatively measured in patients undergoing elective cardiac surgery with (n = 35) or without (n = 11) CPB. Measurements were performed using a Tonopen(®) XL hand-held tonometer at the following five time points in patients with CPB: (1) 30 min after anesthesia induction (baseline), (2) prior to CPB, (3) 60 min after the beginning of CPB, (4) before cessation of CPB, and (5) at the end of operation; and in patients without CPB: (1) 30 min after anesthesia induction (baseline), (2) prior to anastomosis, (3) during left anterior descending artery anastomosis, (4) during left circumflex or right coronary artery anastomosis (head-down position), and (5) at the end of operation. RESULTS: In patients with CPB, IOP values at points 3 and 4 were significantly decreased compared with baseline values and returned to baseline levels at point 5. In patients without CPB, values were significantly increased and peaked at point 4 in the head-down position compared with baseline and prior to anastomosis. CONCLUSION: Results indicate that during cardiac surgery, IOP values decreased during CPB and increased during anastomosis in the head-down position in patients without CPB.

[Spinal epidural hematoma after spinal anesthesia using a 27-gauge spinal needle in a patient with normal coagulation profile].

A 76-year-old man underwent transurethral resection of bladder tumor under spinal anesthesia. Preoperative laboratory date showed normal platelet count (188,000 x microl(-1)) and normal coagulation profile (PT 11.4 sec, APTT 35.1 sec). Lumbar puncture was successfully performed at the L3-4 intervertebral space using a 27-gauge spinal needle with some technical difficulties. Nine hours after the operation, patient suddenly complained of pain from the buttocks to the thighs. Neither motor weakness nor sensory disturbance was found. Therefore conservative therapy was chosen with a diagnosis of transient neurologic symptoms (TNS). However, the subjective symptoms did improve. On the 6th postoperative day, magnetic resonance image (MRI) showed a large epidural hematoma from L1 to L4. On the 13th postoperative day, the subjective symptoms disappeared and MRI on the 17th postoperative day revealed the absence of the hematoma. We should keep in mind that epidural hematoma as well as TNS can occur after spinal anesthesia even with a very fine needle.