Cardiac Arrest During the Medical Management of Left Ventricular Outflow Tract Obstruction Following the Transcatheter Aortic Valve Implantation.

Systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction are complications following transcatheter aortic valve implantation and can lead to hemodynamic collapse. Medical management for those complications is usually centered on a reduction in left ventricular contractility with negative inotropes. An 88-year-old woman underwent transcatheter aortic valve implantation for severe aortic stenosis. Hemodynamic collapse and exacerbation of mitral regurgitation occurred immediately after valve implantation. For suspected left ventricular outflow tract obstruction, medical management centered on negative inotropes was performed. Hemodynamics and left ventricular outflow tract obstruction improved over time; however, the oxygen supply-demand imbalance progressed. On postoperative day 5, the patient suddenly went into pulseless electrical activity. Cardiopulmonary resuscitation was performed for three minutes, resulting in the return of spontaneous circulation. Subsequent refractory hypotension and oxygen supply-demand imbalance improved with continuous infusion of adrenaline, dobutamine, and phenylephrine. Her hemodynamics remained stable after she was weaned off the pressor infusions, and negative inotropes were not required again. In summary, the cause of cardiac arrest was possibly due to excessive negative inotropic effects even though the effects contributed to improvement of left ventricular outflow tract obstruction. Anesthesiologists and intensivists should recognize the risk of cardiac arrest induced by negative inotropic effects and use negative inotropes with rigorous hemodynamic monitoring, even when left ventricular outflow tract obstruction is treated effectively.

Anesthetic Management of a Patient With Central Core Disease Undergoing Thoracoscopic Lung Resection: The Importance of Neuromuscular Monitoring at the Masseter Muscle.

Central core disease is a rare muscular disorder in which anesthetic considerations for the prevention of malignant hyperthermia and for avoidance of residual neuromuscular block are required. A 63-year-old woman with central core disease underwent thoracoscopic sublobar lung resection under total IV anesthesia with a prepared anesthetic workstation. The rocuronium-induced neuromuscular block was monitored by using acceleromyography at the left adductor pollicis muscle and the right masseter muscle. The recovery of neuromuscular block at the masseter was slower than that at the adductor pollicis. The patient showed no symptoms of malignant hyperthermia and residual neuromuscular block and had an uneventful postoperative course. In the present case, malignant hyperthermia was successfully prevented with general anesthesia that is free of triggering agents using a prepared anesthetic machine. The authors speculate that the masseter may be an auxiliary site for neuromuscular monitoring to ensure recovery from neuromuscular block in patients with central core disease.

Airway Management of a Patient With Penetrating Maxillofacial Trauma Caused by Chainsaw Kickback: A Case Report.

Anesthesiologists rarely experience airway management in patients with maxillofacial injuries caused by a chainsaw. A 36-year-old male was referred to our hospital because of maxillofacial injuries caused by chainsaw kickback. There were deep lacerations of the right eyelid, medial canthus, cheek, and jaw with venous bleeding. The laceration of the cheek reached the oral cavity and looked like a "second mouth." The patient was taken to the operating room for urgent laceration repair under general anesthesia. Despite a poor laryngeal view, awake orotracheal intubation with a videolaryngoscope was successful on the second attempt without complications. Oxygenation was optimized by supplemental oxygen administration via a suction catheter inserted from the "second mouth" throughout the airway management. The present case highlights the importance of airway management strategies according to the nature of the trauma in patients with penetrating maxillofacial trauma caused by a chainsaw.

Anesthetic management of a patient with an electroencephalogram phenotype for a "vulnerable brain": a case report.

BACKGROUND: Low frontal alpha power is an electroencephalogram phenotype suggesting vulnerability to anesthetics. This phenotype for a "vulnerable brain" carries risks for burst suppression at lower-than-expected anesthetic concentrations and therefore for postoperative delirium. CASE PRESENTATION: A 73-year-old man underwent a laparoscopic Miles' operation. He was monitored with a bispectral index monitor. Before the skin incision, the fraction of age-adjusted minimum alveolar concentration of desflurane was 0.48, and a spectrogram showed slow-delta oscillation despite a bispectral index value of 38-48. Although the fraction of age-adjusted minimum alveolar concentration of desflurane decreased to 0.33, the EEG signature remained unchanged, along with a similar bispectral index value. No burst suppression patterns were observed throughout the whole procedure, and he did not experience postoperative delirium. CONCLUSIONS: This case suggests that monitoring of electroencephalogram signatures is helpful for detecting patients with a "vulnerable brain" and for providing optimal anesthetic depth in such patients.

Protective effect of UV-irradiated red perilla (Perilla frutescens (L.) Britton) on carbon tetrachloride-induced liver injury in mice.

UV-irradiated red perilla demonstrated promising protective effects against carbon tetrachloride-induced liver injury in mice. UV exposure significantly enhanced the accumulation of rosmarinic acid, malonylshisonin, and shisonin in red perilla, and increased 1,1-diphenyl-2-picrylhydrazyl radical scavenging capacity. The hepatoprotective effect of UV-irradiated red perilla may be attributed to the high level of its polyphenolic compounds, which exhibit antioxidant activity.

A Call for Real-Time Bispectral Index and Electroencephalogram Monitoring in a Patient Undergoing Aortic Surgery.

A 77-year-old woman underwent replacement of the ascending aorta and aortic valve. Before separation from cardiopulmonary bypass, the pump flow was reduced to 0-to-1.1 L/min/m2 for four minutes at a tympanic temperature of 34.3°C to perform additional sutureing for aorta-graft anastomosis. Postoperative magnetic resonance imaging revealed watershed cerebral infarction. An offline scalogram of intraoperative electroencephalograms obtained from the bispectral index monitor, which was generated by using continuous wavelet transform with complex Morlet wavelets, readily visualized the process of development of cerebral infarction preceding a significant decrease of regional cerebral oxygen saturation during the low-flow period of cardiopulmonary bypass. The present case demonstrated the possible importance of real-time bispectral index and electroencephalogram monitoring in patients undergoing cardiovascular surgery, especially those undergoing high-risk procedures under hypothermic circulatory arrest.

Availability of ultrasound imaging of a guidewire parallel to the vein during internal jugular central venous catheter placement.

Ultrasound verification of the guidewire traveling along the vein parallel to it and without any changes in angle has been recommended for prevention of inadvertent arterial catheterization during central venous catheter (CVC) placement. The aim of this study was to determine the availability of this parallel guidewire imaging during internal jugular CVC placement. Fifty-six adult patients undergoing cardiovascular surgery were included. The success rate of acquiring a parallel guidewire image was assessed. Logistic regression models and generalized additive models were used to identify the factors contributing to achieve parallel guidewire imaging. Among 56 patients in whom the guidewire was correctly positioned, the parallel guidewire image was acquired in 45 (80%) patients. Body mass index (crude odds ratio: 0.74 [95% confidence interval: 0.61-0.91]; p = 0.004) and distance from the puncture site to the clavicle (crude odds ratio: 1.32 [95% confidence interval: 1.11-1.58]; p = 0.002) were associated with successful depiction. The predicted probability of successful visualization was 96% (95% confidence interval: 82-99%) when the distance from the puncture site to the clavicle was 50 mm. The distance is a reliable predictor for successful visualization, and thus it should be considered when performing internal jugular CVC placement.

Efficacy of stylet angulation at the holding position during tracheal intubation with a videolaryngoscope: a randomized controlled trial.

The aim of this randomized controlled trial was to determine the efficacy of stylet angulation at the holding position during tracheal intubation with a McGRATH MAC videolaryngoscope. Patients were randomized to a group for intubation without stylet angulation at the holding position (non-angulation group) and to a group for intubation with stylet angulation at the holding position (angulation group). The primary outcome was the time for placement of the tracheal tube. Sixty patients were analyzed. The mean (standard deviation) times for tube placement were 21.3 (5.6) s in the non-angulation group and 16.9 (3.8) s in the angulation group (P < 0.001). The scores of operator's perception of difficulty in tube delivery, number of attempts for tube delivery, and degrees of extension, abduction, internal rotation of the right upper arm and extension of the right wrist during tube placement in the angulation group were significantly smaller than those in the non-angulation group (P < 0.001, P = 0.002, P < 0.001, P < 0.001, P < 0.001, P < 0.001, respectively). Our results suggest that stylet angulation at the holding position improves maneuverability of the tracheal tube and enables easy, smooth, and swift tube placement during tracheal intubation with a McGRATH MAC videolaryngoscope.

Methanol Oxidation at Platinum in Alkaline Media: A Study of the Effects of Hydroxide Concentration and of Mass Transport.

The hydroxide ion concentration dependence of the methanol oxidation reaction at Pt was studied using microelectrode voltammetry and rotating disk electrode voltammetry. Both methods suggest that the rate of methanol oxidation is limited by hydroxide mass transport at low hydroxide concentrations, while it is inhibited by hydroxide adsorption at high concentrations. It was possible to shift from the transport-limited regime to the inhibitory regime by varying the bulk concentration of hydroxide or by varying mass transport to the electrode. Rotating ring-disk electrode voltammetry was employed to qualitatively assess changes in the diffusion layer pH. The results indicated a decrease in the surface pH during methanol oxidation, as expected, but also that the pH reached a steady state during hydroxide transport limited methanol oxidation.

Effect of an aerosol box on tracheal intubation difficulty.

The aim of this study was to determine the effect of an aerosol box on tracheal intubation difficulty. Eighteen experienced anesthetists intubated the trachea of a manikin with a normal airway 6 times using a direct laryngoscope, a McGRATH™ MAC videolaryngoscope, or an airway scope AWS-S200NK videolaryngoscope with or without an aerosol box. Although the aerosol box prolonged the time to successful intubation and decreased the percentage of glottic opening (POGO) score when using a direct laryngoscope, the statistically significant differences were clinically irrelevant. When a McGRATH™ MAC and an AWS-S200NK were used, the times to successful intubation and POGO scores were comparable with and without the aerosol box. When using any of the laryngoscopes, there were no statistically significant differences in the Cormack-Lehane grade and peak force to maxillary incisors with and without the aerosol box. In summary, the effect of an aerosol box on tracheal intubation difficulty is not clinically relevant when an experienced anesthetist intubates the trachea in a normal airway condition.

Anesthetic management of a patient with musculocontractural Ehlers-Danlos syndrome undergoing scoliosis surgery.

BACKGROUND: Musculocontractural Ehlers-Danlos syndrome is a new and rare subtype of Ehlers-Danlos syndrome in which anesthetic considerations for airway and respiratory management, prevention of skin injuries and joint dislocations, and hemostatic management for severe perioperative bleeding are required. CASE PRESENTATION: A 19-year-old woman with musculocontractural Ehlers-Danlos syndrome was scheduled to undergo posterior spinal fusion from the 4th thoracic to the 4th lumbar vertebrae under general anesthesia. Her trachea was easily intubated with a videolaryngoscope despite a small mouth and micrognathia. Pressure-controlled ventilation with limited peak inspiratory pressure was performed for prevention of pneumothorax. Skin damage and joint luxation were prevented by using a low rebounding mattress, terpolymer-based barrier film, and careful patient positioning. Blood transfusion was effectively performed on the basis of point-of-care viscoelastic hemostatic assay monitoring. She had an uneventful postoperative course without any complications. CONCLUSIONS: We safely managed a patient with musculocontractural Ehlers-Danlos syndrome undergoing scoliosis surgery.

Severe mitral regurgitation due to geometric changes in the mitral valve after surgical aortic valve replacement.

BACKGROUND: Severe mitral regurgitation (MR) after aortic valve replacement (AVR) is a serious complication. Although several causes of MR after AVR have been reported, severe MR due to geometric changes in the mitral valve imposed by an aortic valve prosthesis has not been reported. We here report a case of severe MR after AVR that was improved after re-AVR. CASE PRESENTATION: A 77-year-old male underwent elective total aortic arch replacement and AVR. Mild MR was preoperatively identified. After surgery and separation from cardiopulmonary bypass, transesophageal echocardiography (TEE) demonstrated restriction and distortion of the anterior mitral leaflet and severe MR. Displacement of the anterior mitral annulus by the prosthetic aortic valve was strongly suspected to be the cause of MR, which should be surgically restored. Re-AVR using a small-sized valve was then performed. Consequently, the structural changes in the mitral valve were reverted and the MR was reduced. CONCLUSIONS: Geometric changes in the mitral valve induced by an aortic valve prosthesis can cause massive increment of MR. Intraoperative TEE examination of the mitral apparatus is important when severe MR occurs after AVR.

Perioperative Characteristics of the Accuracy of Subcutaneous Continuous Glucose Monitoring: Pilot Study in Neurosurgery and Cardiac Surgery.

BACKGROUND: The aim of this study was to elucidate the characteristics of accuracy of subcutaneous continuous glucose monitoring (SCGM) in the perioperative period for neurosurgical and cardiac surgery patients. METHODS: Forty-five subjects, including healthy volunteers (n = 15), neurosurgical patients (n = 15), and cardiac surgery patients (n = 15), were enrolled. A subcutaneous sensor of the MiniMed™ 620G SCGM system was inserted into the upper arm. On the day after sensor insertion, SCGM data and blood glucose data were collected simultaneously and compared. In cardiac surgery patients, data were continuously collected on postoperative day (POD) 1 and POD 3. Clarke error grid analysis and Bland-Altman analysis were performed to assess the accuracy of SCGM. RESULTS: Clarke error grid analysis showed clinical acceptance of the SCGM system with 82.7% and 86.8% of the data being within zone A for healthy volunteers and neurosurgical patients, respectively. Mean biases were -2.1 mg/dL in healthy volunteers and -8.3 mg/dL in neurosurgical patients. In cardiac surgery, although Clarke error grid analysis showed clinical acceptance, 65.3% of the data were within zone A and mean bias was -23.5 mg/dL. Changes in accuracy of SCGM in individuals occurred during cardiopulmonary bypass (CPB), and SCGM tended to show a lower glucose level. On POD 1 and POD 3, the accuracy improved, and 85.0% and 86.3% of the data were within zone A. CONCLUSIONS: Although the accuracy of the SCGM system was clinically acceptable in the perioperative period, sensor accuracy was affected by CPB and showed lower glucose levels.

Glucose Management during Insulinoma Resection Using Real-Time Subcutaneous Continuous Glucose Monitoring.

Insulinoma is a rare neuroendocrine tumor that causes hypoglycemia due to unregulated insulin secretion. Blood glucose management during insulinoma resection is therefore challenging. We present a case in which real-time subcutaneous continuous glucose monitoring (SCGM) in combination with intermittent blood glucose measurement was used for glycemic control during surgery for insulinoma resection. The SCGM system showed the trends and peak of interstitial glucose in response to glucose loading and the change of interstitial glucose before and after insulinoma resection. These data were helpful for adjusting the glucose infusion; therefore, we think that an SCGM system as a supportive device for glucose monitoring may be useful for glucose management during surgery.

Considerable Enhancement of Emission Yields of [Au(CN)2(-)] Oligomers in Aqueous Solutions by Coexisting Cations.

The photophysical properties of [Au(CN)2(-)] oligomers in aqueous solutions were investigated as functions of coexisting cations as well as the viscosity and temperature of solutions. A solution of [Au(CN)2(-)] in the concentration range of 0.03-0.2 mol/dm(3) exhibited emission peaks at 460-480 nm because of the presence of oligomers larger than trimers. Although the emission yields (ϕem) of K[Au(CN)2] solutions were <1%, it considerably increased to 43% when 1.0 mol/dm(3) tetraethylammonium chloride (Et4NCl) was added. The lifetimes of the main emission bands were also significantly varied with additional salts, e.g., KCl, 15 ns; Et4NCl, 520 ns. The time-resolved emission measurements of [Au(CN)2(-)] in a water/glycerol mixture indicated that the lifetimes were almost directly proportional to the inverse of the viscosity of the solution. On the other hand, the intrinsic lifetimes of dimers and trimers with weak emission in shorter wavelength regions were very short and independent of the viscosity of the solutions and coexisting cations (dimer, ∼25 ps; trimer, ∼2 ns). These results indicated that the deactivation of the excited-state [Au(CN)2(-)]n oligomers (n ≥ 4) was dominated by the dissociation of the oligomers to a shorter species (dimer or trimer). The hydrophobic interactions between tetraalkylammonium cations and CN ligands remarkably stabilized the larger oligomers and suppressed the dissociation of the excited-state oligomers, which enhanced the emission yield of the oligomers. This work provides a new method of "exciplex tuning" by changing the environment of excited-state [Au(CN)2(-)]n oligomers.

Coherent vibration and ultrafast dynamics upon bond formation in excited dimers of an Au(I) complex.

Au-Au bond strengthening in photoexcited dimers of an Au(I) complex is captured in solution as oscillations of femtosecond absorption signals. The subsequent dynamics, when compared to the trimer's data, confirm that the bent-to-linear structural change of the trimer occurs in the first few picoseconds.

A modified sol-gel technique for pore size control in porous aluminum oxide nanowire templates.

A modified sol-gel technique was developed to continuously vary the pore diameters in porous alumina templates for the purpose of growing nanowires. To coat the pore walls, the porous alumina film is initially soaked in a methanol/water solution to fill the pores with the desired concentration of water. The porous alumina film is then exposed to a solution of 3-aminopropyltriethoxysilane (APTES) in toluene, creating a surface layer of APTES. The concentration of water in the pores correlates with the thickness of the APTES polymer coating that is obtained. This approach exerts greater control over the extent of silane polymerization than traditional sol-gel reactions by limiting the amount of water present for reaction. Factors such as the APTES concentration, exposure time, and organic cosolvent choice did not influence the coating thickness. However, the density and thickness of the APTES coating can be manipulated by varying the pH of the methanol/water solution as well as post-treatment annealing. Further modification of the pore size was achieved by subsequent reaction of the APTES coating with poly(methyl methacrylate) (PMMA). The PMMA couples to amine groups on the APTES polymer surface by an aminolysis reaction. Bismuth telluride nanowires were electrodeposited in the polymer-coated porous alumina templates using previously established methods. Nanowire diameters were smaller when the nanowires were prepared in modified templates as anticipated.