Genetic profiles of fluoroquinolone-nonsusceptible Klebsiella pneumoniae among cephalosporin-resistant K. pneumoniae.

The rate of fluoroquinolone (FQ) resistance among the cephalosporin-resistant Klebsiella pneumoniae is considerably high, however, their genetic profiles have not been well investigated. We selected 61 ciprofloxacin-nonsusceptible isolates from 102 K. pneumoniae isolates judged to be "resistant" to some cephalosporins during 2009 and 2012 throughout Japan. Pulsed-field gel electrophoresis excluded clonal isolates, and 29 isolates were subjected to multilocus sequence typing (MLST), detection of the amino acid substitutions in the quinolone resistance determining regions (QRDRs) of GyrA and ParC, ß-lactamase typing, and identification of plasmid-mediated quinolone resistance (PMQR) genes. PCR-based replicon typing was performed, after PMQR gene transfer. Four major sequence types (STs) or clonal complexes (CCs), that is, ST37, CC17 (consisting of ST17 and ST20), ST11, and CC528 (consisting of ST528 and ST1130), were found, and they accounted for 48.2% of the isolates tested. Amino acid substitutions in the QRDRs and the presence of PMQR genes were identified in 20 (68.9%) and 18 (62.0%) isolates, respectively. The replicon type of three PMQR-carrying plasmids was IncN, but others were nontypable. Fifteen (83.3%) of the 18 PMQR-harboring isolates coharbored blaCTX-M and/or blaDHA-1. Ciprofloxacin-nonsusceptible K. pneumoniae clinical isolates demonstrating cephalosporin resistance often belong to the global epidemic lineages and possess PMQR and/or QRDR substitutions.

[Efficacy and safety of remifentanil-based regimen for postoperative pain management in abdominal surgery patients: a double-blind study with low-dose remifentanil infusion of 0.02 microg x kg(-1) x min(-1)].

BACKGROUND: Remifentanil is a powerful analgesic with fast onset and ultra-short duration of action. Its context-sensitive half-time is consistently short even after a prolonged infusion. Remifentanil is effective for providing better postoperative analgesia, but this method is not generally accepted in Japan. The present study was conducted to document efficacy and safety of low-dose remifentanil infusion in postoperative patients. METHODS: Forty patients undergoing abdominal surgery were studied prospectively. They were randomly assigned to either remifentanil (0.02 microg x kg(-1) x min(-1)) or placebo group. Postoperatively all patients received continuous epidural anesthesia with lidocaine and IV patient-controlled analgesia with fentanyl. Flurbiprofen was administered only when no pain relief was achieved. Visual analogue scale (VAS), requirement of fentanyl and flurbiprofen, and the incidence of remifentanil-related adverse effects (respiratory depression, nausea, vomiting, pruritus) were examined at 3 hourly intervals for 12 hours. RESULTS: There are no statistical differences between two groups in pain scores. No adverse events including respiratory depression occurred throughout the study in both groups. CONCLUSIONS: Remifentanil infusion at 0.02 microg x kg(-1) x min(-1) can safely be used without any serious adverse events, while it may not be enough for postoperative analgesia. The best dosage of this drug for postoperative analgesia remains to be elucidated.

[The evaluation of total body water composition during caesarean section under spinal anesthesia].

BACKGROUND: Hypotension is a common adverse effect of spinal anesthesia (SA). Preoperative fluid infusion is recommended to prevent hypotension during caesarean section. The aim of this study is to document relationship between preoperative total body water (TBW) and the amount of the vasopressors given intraoperatively and to evaluate the change of maternal body water composition (BWC). METHODS: In 57 patients scheduled for caesarean section under SA, maternal BWC was measured by bioelectrical impedance analysis method. SA was performed using 0.5% isobaric bupivacaine 2 ml and fentanyl 20 microg at L3-4 intervertebral space. After this procedure, the impedance was measured again. We investigated the correlation between TBW and the amount of the vasopressor and the change of maternal BWC before and after SA. RESULTS: No positive linear correlation existed between the preoperative TBW and the amount of vasopressors given intraoperatively. SA produced a 3.8% increase in TBW and a 4.7% increase in extracellular water (ECW, P < 0.01). CONCLUSIONS: Preoperative TBW does not affect the amount of vasopressors given during caesarean section, which suggested massive fluid infusion can not always prevent hypotension after SA. A slight changes in TBW and ECW may be induced by SA, while the exact physiological and clinical significance of these observation remains to be elucidated.

[A case-control study of airway management for 68 patients with cervical spine injury: comparison of the direct laryngoscope with a Macintosh blade and the fiberoptic bronchoscope].

BACKGROUND: As for cervical spine injury, special consideration for airway management is required but the optimal strategy remains controversial. Direct laryngoscopy (DL) creates some degree of cervical extension leading to secondary neurologic deterioration. Fiberoptic bronchoscopy (FOB) may facilitate tracheal intubation with little cervical motion, but has several inherent limitations. A few objective data prompted us to compare the neurologic outcome relating to the orotracheal intubation using the different types of technique, the DL with a Macintosh blade or the FOB. METHODS: To identify the effect of different methods on the intubation time, neurologic disability, and adverse effects, 68 cervical spine-injured patients with the use of DL (group L; 36 patients) or FOB (group F; 32 patients) were retrospectively reviewed using hospital records. Following the induction of general anesthesia, the trachea was intubated with no immobilizing forces in group L, while awake intubation was accomplished in group F after judicious application of local anesthesia to the larynx and trachea. RESULTS: No significant differences were observed between the groups in age, BMI, intubation time, postoperative neurologic outcome or incidence of aspiration pneumonia. Moreover, no neurologic deterioration was shown after DL and orotracheal intubation. CONCLUSIONS: We found no evidence to support the routine practice of the bronchoscope-assisted awake intubation in patients with cervical spine injury. The clinical value of this technique in offering some neurologic advantage remains limited.

[Case of obstructive sleep apnea possibly having led to postoperative appearance of generalized convulsion].

Adverse surgical outcomes appear to be more frequent in patients with known obstructive sleep apnea (OSA). However, OSA patients may present for surgery without a prior diagnosis. A 37-year-old man underwent craniotomy for surgical direct neck clipping of the right ruptured internal carotid aneurysm. His intraoperative and early postoperative courses were uneventful. At night, about 48 hr after surgery, he developed sudden generalized tonic-clonic convulsion and temporary depressed consciousness resulting in marked hypercapnea (Pa(CO2)>100 mmHg). His respiration was transiently supported by PSV mode via LMA. He soon got well without neurologic deficits. At night, about 74 hr postoperatively, a generalized convulsion was again observed with hypercapnea. Aside from the respiratory support, percutaneous cricothyroidotomy was performed using Minitrach II system for his airway control, leading to no further recurrence of seizure. He was suspected to have unrecognized OSA due to such characteristic findings of sleep apnea as obesity (BMI>30) and witnessed apneas by his family. Postoperative rapid eye movement (REM) sleep rebound has been suggested to contribute to two consecutive night appearance of seizure. Clinical suspicion for OSA should be required preoperatively and perioperative heightened awareness is recommended.

[Cardiac arrest induced by dexmedetomidine].

A 64-year-old woman with hypertension, diabetes mellitus and asymptomatic first degree AV block underwent low anterior resection of the rectum. Anesthesia was induced with propofol, vecuronium bromide and remifentanil and maintained with nitrous oxide in oxygen, propofol and remifentanil. We did not use epidural anesthesia. After the operation, the patient was admitted to the intensive care unit under general anesthesia with propofol and remifentanil. In addition, dexmedetomidine was given without loading dose. The EKG changed from first degree AV block to second degree AV block followed by complete AV block and finally cardiac arrest. As soon as we performed heart massage, sinus rhythm appeared. We should be careful in giving dexmedetomidine to a patient with AV block.