Perioperative Management of a Needle-Phobic Parturient for a Cesarean Section: A Case Report.

We describe the perioperative management of a pregnant woman with severe needle phobia who underwent a cesarean section. General anesthesia with slow induction using an inhalant anesthetic for cesarean section is a rare and unique situation. Furthermore, the management of this case was more complicated because the patient not only refused the puncture procedure but also refused the presence of an indwelling object when she woke up from the anesthesia. After the operation, the patient was admitted to the intensive care unit (ICU) and received mechanical ventilation under deep sedation. The patient was managed under sedation until the day after surgery, and both mother and child progressed without perioperative complications.

The combination of doxazosin and metyrosine as a preoperative treatment for pheochromocytomas and paragangliomas.

PURPOSE: Preoperative medical management is critical to prevent intraoperative cardiovascular complications in patients with pheochromocytomas and paragangliomas (PPGLs). Initial treatment involves α-adrenergic receptor blockers. However, while the routine use of metyrosine alongside these blockers is not strongly recommended due to a lack of evidence supporting its efficacy and associated safety concerns, there are previous studies on combination therapy with phenoxybenzamine and metyrosine. There are few reports on combination therapy with the selective α1-adrenergic receptor blocker doxazosin. Therefore, we investigated this combination treatment, which theoretically can affect perioperative outcomes in patients with PPGLs. To our knowledge, this is the first such study. METHODS: This retrospective single-center observational study involved 51 patients who underwent surgical resection of PPGLs at Kobe University Hospital between 2014 and 2022. All patients received doxazosin at maximum doses. Fourteen patients received concomitant metyrosine, while 37 received doxazosin alone. Their perioperative outcomes were compared. RESULTS: No severe event, such as acute coronary syndrome, was observed in either group. Intraoperatively, the doxazosin + metyrosine group exhibited a lower median minimum systolic blood pressure (56 [54-60] vs. 68 [59-74] mmHg, P = 0.03) and required lower median remifentanil (P = 0.04) and diltiazem (P = 0.02) doses than the doxazosin-alone group. CONCLUSION: The combination of metyrosine and doxazosin as a preoperative treatment for PPGLs affects intraoperative circulatory hemodynamics, such as a reduced occurrence of blood pressure elevation during surgery. Further research is necessary to identify patients who will benefit most from this combination treatment.

A Case of a Highly Obese Covid-19 Patient with Severe Hypoxemia and Subcutaneous Mediastinal Emphysema Who Was Rescued by Early Introduction of ECMO.

We conducted the treatment of a highly obese patient with severe Covid-19 pneumonia who had a history of asthma. When she arrived at the hospital, she was already intubated and had mediastinal emphysema and severe hypoxemia. Because the patient's condition did not improve with mechanical ventilation, we introduced extracorporeal membrane oxygenation (ECMO) immediately after admission. The patient improved with early induction of ECMO and prone positioning. In the management of patients with severe Covid-19 pneumonia, early introduction of ECMO should be considered if oxygenation does not improve with mechanical ventilation, and prone positioning can also be effective.

The association of intraoperative end-tidal carbon dioxide with the risk of postoperative nausea and vomiting.

PURPOSE: Patients undergoing gynecological surgery are considered to be a high-risk cohort for postoperative nausea and vomiting (PONV). The purpose of this study was to assess the association of intraoperative end-tidal carbon dioxide (EtCO2) with risk of PONV in patients underwent gynecological open surgery. METHODS: In this single-center retrospective observational study, we included patients aged 20-60 years who underwent elective gynecological open surgery. We obtained data for the incidence of PONV within 24 h after operation. We collected EtCO2 every minute during the operation, and determined the lowest value of EtCO2. We compared the lowest EtCO2 between patients with and without PONV. Multivariate logistic regression analysis was performed to assess the independent association of EtCO2 with the risk of PONV. RESULTS: A total of 146 patients were included in the current study. There were 81 patients with PONV within 24 h after the operation. The median lowest value of EtCO2 in patients with PONV was significantly lower than that in patients without PONV (31 vs 33 mmHg, p = 0.02). In the multivariate logistic regression model, we found that lowest EtCO2 ≤ 31 mmHg was independently associated with increase in the risk of PONV (adjusted odds ratio = 3.37, p = 0.02). CONCLUSION: In this retrospective observational study, low intraoperative EtCO2 was shown to be independently associated with increased risk of PONV. However, this result may be skewed by uncollected information including previous PONV, motion sickness or other unknown bias, so future studies should be conducted to refute or confirm our findings.

Using Turmeric Oil as a Solvent Improves the Distribution of Sesamin-Sesamolin in the Serum and Brain of Mice.

Accumulation of amyloid-ß peptide is associated with Alzheimer's dementia. Previously, we reported that sesamin and sesamolin inhibited ß-secretase activity in vitro, and each was transported to the serum and brain in mice after oral administration. However, the bioavailability of sesamin and sesamolin was poor in mice. In this study, we aimed to improve the bioavailability of sesamin and sesamolin. We found that the levels of sesamin and sesamolin in mouse serum and brain were higher after the administration of a mixture of sesame extract and turmeric oil (MST) than those after administering sesame extract alone. Serum sesamin and sesamolin contents in the MST-treated group were 23-fold and 15-fold higher, respectively, than those in the sesame extract-treated group. Brain sesamin and sesamolin contents in the MST-treated group were 14-fold and 11-fold higher, respectively, than those in the sesame extract-treated group. These results suggest that turmeric oil is an effective solvent to enhance the bioavailability of sesamin and sesamolin.

The impact of intravenous isotonic and hypotonic maintenance fluid on the risk of delirium in adult postoperative patients: retrospective before-after observational study.

PURPOSE: To assess the impact of intravenous isotonic and hypotonic maintenance fluid on the risk of delirium in adult postoperative patients, we conducted retrospective before-after study in a tertiary teaching hospital. METHODS: We examined all adult patients admitted ICU after an elective operation for head and neck cancer, or esophageal cancer from February 2014 to January 2017. From February 2014 to July 2015, patients were administered hypotonic fluid (sodium; 35 mmol/L) as the National Institute for Health and Care Excellence (NICE) have recommended. From August 2015 to January 2017, patients were administered isotonic fluid (sodium; 140 mmol/L). We defined the incidence of delirium as the primary outcome. The delirium was defined as the Intensive Care Delirium Screening Checklist during the ICU stay ≥ 4. A propensity score-matched model was used to adjust confounders. RESULTS: As postoperative intravenous maintenance fluid, hypotonic fluid was administered to 119 patients and isotonic fluid was administered to 92 patients. Among those total cohorts, the incidence of postoperative delirium in the hypotonic group was 21.8%, which was significantly higher than that (9.8%) in the isotonic group (p = 0.019). After propensity score matching, we selected 77 patients in each group. The incidence of delirium during the ICU stay in the hypotonic group was 26.0%, which was significantly higher than the incidence of 11.7% in the isotonic group (p = 0.023). CONCLUSIONS: In this study, the use of postoperative hypotonic maintenance fluid was associated with a higher risk of postoperative delirium than that when isotonic maintenance fluid was used.

Anesthetic Management of Transcatheter Aortic Valve Replacement under Extracorporeal Membrane Oxygenation in a Patient with Acute Decompensated Heart Failure: A Case Report.

We managed general anesthesia for transcatheter aortic valve replacement (TAVR) under elective extracorporeal membrane oxygenation (ECMO) in a patient with aortic valve stenosis (AS) complicated with acute decompensated heart failure. The patient was an 87-year-old woman with acute heart failure due to severe AS who had been hospitalized. However, her low cardiac output did not improve, and weaned her off catecholamines was difficult, so semi-urgent TAVR was performed. Due to her acute decompensated heart failure complicated by low-left ventricular function, we decided electively to use ECMO for transfemoral TAVR to prevent hemodynamic collapse during induction of anesthesia and surgery, enabling the safe perioperative management of this patient under general anesthesia.

Association of direct bilirubin level with postoperative outcome in critically ill postoperative patients.

BACKGROUND: Hyperbilirubinemia is a common postoperative complication. Elevated direct bilirubin (D-Bil) and indirect bilirubin (I-Bil) levels are related to different pathophysiologies; therefore, their associations with outcomes also differ. However, there have been few comparative studies of such associations in postoperative patients. METHODS: This retrospective study compared the associations of postoperative D-Bil and I-Bil with outcomes. We included adult patients requiring postoperative intensive care for more than 48 hours between 2008 and 2013, except those undergoing liver operations. The number of patients was determined using a power calculation. D-Bil and I-Bil measurements were obtained on postoperative days (POD) 1 and 2. The primary outcome was defined as hospital mortality, with the number of ICU-free survival days (IFSD) at POD 28 as the secondary outcome. RESULTS: The study population consisted of 1,903 patients with a mortality rate of 2.2%. D-Bil at POD 1 was significantly higher in non-survivors than survivors (P = 0.001), but I-Bil at POD 1 showed no such relation (P = 0.209). Multivariate logistic analysis indicated that higher postoperative D-Bil was independently associated with increased postoperative mortality (POD 1: adjusted odds ratio [OR] = 2.32, P < 0.001; POD 2: adjusted OR = 1.95, P < 0.001), but I-Bil showed no such relation (POD 1: P = 0.913; POD 2: P = 0.209). Increased D-Bil was independently associated with decreased IFSD at POD 28 (POD 1: adjusted coefficient = -1.54, P < 0.001; POD 2: -1.84, P < 0.001). In contrast, increased I-Bil at POD 1 was independently associated with increased IFSD at POD 28 (POD 1: adjusted coefficient = +0.39, P = 0.021; POD 2: +0.33, P = 0.080). CONCLUSIONS: D-Bil indices have a higher capability than I-Bil for predicting poorer outcomes in critically ill postoperative patients.

Glycemic control in acute illness.

Hyperglycemia is commonly observed in critical illness. A landmark large randomized controlled trial (RCT) reported that the incidence of hyperglycemia (blood glucose concentration > 108 mg/dl) was as high as 97.2% in critically ill patients. During the past two decades, a number of RCTs and several meta-analyses and network meta-analyses have been conducted to determine the optimal target for acute glycemic control. The results of those studies suggest that serum glucose concentration would be better to be maintained between 144 and 180 mg/dl. Although there have been studies showing an association of hypoglycemia with worsened clinical outcomes, a causal link has yet to be confirmed. Nonetheless, some researchers are of the view that the data suggest even mild hypoglycemia should be avoided in critically ill patients. Since acutely ill patients who receive insulin infusion are at a higher risk of hypoglycemia, a reliable devices for measuring blood glucose concentrations, such as an arterial blood gas analyzer, should be used frequently. Acute glycemic control in patients with premorbid hyperglycemia is a novel issue. Available literature suggests that blood glucose concentrations considered to be desirable and/or safe in non-diabetic critically ill patients might not be desirable in patients with diabetes. Moreover, the optimal target for acute blood glucose control may be higher in critically ill patients with premorbid hyperglycemia. Further study is required to assess optimal blood glucose control in acutely ill patients with premorbid hyperglycemia.

Association between Intra-Circuit Activated Clotting Time and Incidence of Bleeding Complications during Continuous Renal Replacement Therapy using Nafamostat Mesilate: a Retrospective Pilot Observational Study.

It has been proposed that anticoagulant activity during continuous renal replacement therapy with nafamostat mesilate can be monitored by using intra-circuit activated clotting time. However, it is still unclear whether activated clotting time would be useful for this purpose. We conducted a retrospective study and included 76 patients who required continuous renal replacement therapy using nafamostat mesilate. We obtained information for pre- and post-filter activated clotting times and bleeding complications. We calculated time-weighted average activated clotting time. We divided the patients into three activated clotting time groups (low, middle, high) according to the tertiles of pre- and post-filter activated clotting times. Regarding post-filter time-weighted average activated clotting time, the incidence of bleeding complications in the high activated clotting time group was significantly higher than those in the low and middle activated clotting time groups (p=0.04). The incidences of bleeding complications were not significantly different among the three groups according to pre-filter time-weighted average activated clotting time (p=0.35). In sensitive analysis, the duration on continuous renal replacement therapy without bleeding complications was significantly longer for filters with post-tw ACT<262 than for those with post-tw ACT≥262 (p=0.03). This result suggested that post-filter time-weighted average activated clotting time might be a good predictor of bleeding complications during continuous renal replacement therapy with nafamostat mesilate. Further study is required to refute or confirm our findings.

Comparison of nafamostat mesilate and unfractionated heparin as anticoagulants during continuous renal replacement therapy.

PURPOSE: Nafamostat mesilate (NM) can be used as a regional anticoagulant for continuous renal replacement therapy (CRRT). The primary aim of this study was to assess the association of the use of NM with risk of bleeding complications and compare it with the use of unfractionated heparin (UFH). METHODS: We conducted a single-center retrospective observational study. We included adult patients who required CRRT in our intensive care unit from 2011 to 2013. The primary outcome was the risk of bleeding complications during CRRT and the secondary outcome was filter life for the first filter of CRRT. RESULTS: We included 101 patients (76 with NM, 25 with UFH). Among the 101 patients, use of NM tended to be associated with lower risk of bleeding complications (6.6% vs. 16%; odds ratio, 0.37; p = 0.16). Propensity score matching generated 30 patients with NM and 15 patients with UFH with well-balanced baseline characteristics. Among the propensity score-matched cohorts, use of NM was significantly associated with decreased risk of bleeding complications (3.3% vs. 27%; odds ratio, 0.09; p = 0.04). In multivariate logistic analysis using the inverse probability of treatment weighting for sensitive analysis, the use of NM was independently associated with reduced risk of bleeding complications (p = 0.02). The median filter life was not significantly different for patients with NM and patients with UFH (25.5 hours vs. 30.5 hours, p = 0.16). CONCLUSIONS: In our retrospective analysis, the use of NM as an anticoagulant during CRRT was associated with decreased incidence of bleeding complications compared with the use of UFH.

[Anesthetic management of a patient with hemophilia B during scoliosis surgery].

Posterior spinal fusion for scoliosis was planned in a 14-year-old male patient with hemophilia B. Preoperative examination showed factor IX activity of 8.4% with no inhibitor development. A perioperative dosage schedule was prepared after examining the pharmacokinetics of recombinant coagulation factor IX in order to maintain levels of perioperative factor IX activity at < or = 80% for the first 6 days (days 0-6), and > or = 40% for days 7-14 postoperatively. The dose of recombinant coagulation factor IX was adjusted to maintain factor IX activity above 80%, while measuring coagulation activity every hour during the surgery. The patient showed a favorable course without hemorrhagic tendency. We could safely manage anesthesia without requiring allogeneic blood transfusion.