Ultrasonographic images of spina bifida before obstetric anesthesia: a case series.

BACKGROUND: Spina bifida is a relatively common congenital malformation. As the functional prognosis of patients with spina bifida has improved over time, the number of cases resulting in pregnancy and delivery has increased. Lumbar ultrasonography has become a standard and helpful technique before neuraxial anesthesia. We believe that it might be valuable if we use lumbar ultrasonography to evaluate pregnant women with spina bifida before obstetric anesthesia. CASE PRESENTATION: We performed lumbar ultrasonography to evaluate four pregnant women with spina bifida. Patient 1 had no history of surgery. Lumbar radiography before pregnancy showed a bone defect from L5 to the sacrum as a result of incomplete fusion. Magnetic resonance imaging showed a spinal lipoma and a bone defect of the sacrum. Lumbar ultrasonography showed similar findings. We performed general anesthesia for emergency cesarean delivery. Patient 2 underwent surgical repair immediately after birth. Lumbar ultrasonography showed the same bone defect as well as a lipoma beyond the bone defect. We performed general anesthesia for cesarean delivery. Patient 3 had vesicorectal disorders but no prior surgery. Lumbar radiography before pregnancy showed congenital abnormalities such as incomplete fusion, scoliosis, rotation, and a notably small sacrum. Lumbar ultrasonography showed the same bone defect. We performed general anesthesia for cesarean section with no complications. Patient 4 complained of lumbago a few years after her first delivery and received a diagnosis of spina bifida occulta by lumbar radiography, with the incomplete fusion of only the 5th vertebra. Lumbar ultrasonography indicated the same abnormalities. We placed an epidural catheter to avoid the bone abnormality and achieved epidural labor analgesia with no complications. CONCLUSIONS: Lumbar ultrasonography shows anatomic structures easily, safely, and consistently, without X-ray exposure or the need for more expensive modalities. It is a helpful technique to explore anatomic structures potentially complicated by spina bifida before anesthetic procedures.

Clinical outcomes in pregnant women with coronavirus disease 2019 in a perinatal medical centre in Japan: a retrospective study of the first 1 year of the pandemic.

In this retrospective study, we analysed clinical and demographic data from the medical records of 31 pregnant women with coronavirus disease 2019 (COVID-19) who were treated at our hospital between April 2020 and April 2021. The most common symptom was a fever; ∼10% of patients were asymptomatic. One patient with rapidly worsening pneumonia needed a Caesarean Section at 30 weeks and was admitted for intensive care. Twelve patients received perinatal care in our hospital (10 live births, one stillbirth, and one artificial abortion). Six patients delivered vaginally; the others delivered via caesarean section. Two patients had complications, including severe hypertensive disorders and preeclampsia. All patients recovered from COVID-19. Severe acute respiratory syndrome coronavirus 2 was not detected in the placenta, umbilical cord, cord blood, amniotic fluid, vaginal fluid, or breast milk in any patient. There were no neonatal adverse outcomes. The possibility of transmitting the coronavirus to pregnancy-related samples was low.IMPACT STATEMENTWhat is already known on the subject? COVID-19 has been affecting different countries in diverse ways, and the incidence, mortality, and morbidity rates of patients with COVID-19 vary widely by country or region and race. These differences in results may reflect racial differences and differences in national health care systems. Moreover, the information about the perinatal outcomes of pregnant women with COVID-19 and their newborns from Japan is limited.What do the results of this study add to what is known? We described the perinatal outcomes of 31 Japanese pregnant women with COVID-19 who were managed safely in a perinatal medical centre in Tokyo Japan, during the first 1 year of the pandemic.What are the implications of these findings for clinical practice and/or further research? Severe pneumonia and perinatal complications may occur, although no maternal and neonatal deaths were observed for COVID-19-positive pregnant women in our facility. Therefore, it is important to prevent this infection during pregnancy with the provision of effective medical care.

[Anesthesia for an Eleven Year Old Girl with Sjögren-Larsson Syndrome].

Sjögren-Larsson syndrome (SLS) is an autosomal recessive disease characterized by a triad of congenital ichthyosis, spastic quadriplegia and mental retardation. An 11-year-old girl (body weight 30 kg) diagnosed as SLS was admitted with Benett fracture of the right thumb. She was monitored with standard protocol. General anesthesia was induced by rapid induction method with propofol 50 mg and rocuronium 0.6 mg - kg⁻¹. She was ventilated with bag and mask, and intu- bated without difficulty. Neuromuscular function was continuously assessed by 40 mA-TOF-stimulation re- sponses with acceleromyography immediately after induction of general anesthesia by TOF-Watch® SX (Organon Ireland, division of MSD, Ireland). Anesthe- sia was maintained with total intravenous anesthesia with propofol 6-8-10 mg⁻¹ · hr⁻¹ in oxygen. No abnor- mal responses were observed by TOF-Watche SX despite the neuromuscular disease. Residual effect of the neuromuscular blocking agent was successfully reversed by sugammadex and she was extubated without any respiratory trouble. She was discharged on the postoperative day 1 without complications.

[Safety of oral rehydration therapy in endoscopic surgery patients].

BACKGROUND: To test safety and efficacy of ORT (oral rehydration therapy), we compared an ORT group with an intravenous infusion (i.v.) group by gastric fluid (volume and pH) obtained by endoscope and gastric ultrasonography examination. METHODS: Twenty six patients scheduled for endoscopic surgery were assigned to an ORT group or an i.v. group by standardized clinical path. After gastric ultrasonography examinations to calculate CSA (cross sectional area) of gastric antrum, general anesthesia was induced. Immediately after anesthesia induction, gastric fluid was obtained by endoscopy, and its volume and pH were measured. RESULTS: Fifteen and eleven patients were assigned to ORT group and iv group, respectively. In ORT group, CSA was median 1.9 cm2 (95% CI:1.8-2.6 cm2), gastric volume was median 11 ml (95% CI: 8-18 ml) and pH was median 3.6 (range: 1.2-8.8), and in i.v. group CSA was median 1.8 cm2 (95% CI: 1.6-2.7 cm2), gastric volume was median 4 ml (95% CI: 3-12 ml), and pH was median 3.1 (range: 1.2-7.2). There was no significance between the two groups. CONCLUSIONS: Gastric volume in ORS group was not smaller compared with that in i.v. group, and there was no significant difference in pH between the groups.

[Reversal of rocuronium-induced neuromuscular blockade with sugammadex in patients for cesarean delivery treated with magnesium sulfate].

BACKGROUND: We investigated whether sugammadex could reverse neuromuscular blockade induced by rocuronium in patients for cesarean delivery treated with magnesium sulfate preoperatively. METHODS: Twenty-three pregnant women received general anesthesia induced with thiopental and rocuronium. They were maintained by nitrous oxide, oxygen and sevoflurane (GOS) before delivery and after delivery by GOS, midazolam, and propofol. After the surgery, the patients with two or more counts of train-of-four (TOF), the moderate block group were classified into Mg (-) M and Mg (+) M, depending whether magnesium sulfate had been injected or not, and sugammadex 2 mg x kg(-1) was administered to both groups. Patients with PTC 2 or more, the profound block group, were classified into Mg (-) P or Mg (+) P and sugammadex 4 mg x kg(-1) was administered to both groups. Recovery time was defined as the time required to reach TOFR 0.9 or more after the injection of sugammadex. RESULTS: Median recovery times of the Mg (-) M, the Mg (-) P, the Mg (+) M and the Mg (+) P were 63 seconds (range: 26-130, N = 7), 127 seconds (range: 63-228, N = 7), 104 seconds (range: 67-133, N = 5), and 142 seconds (range: 57-209, N = 4), respectively. CONCLUSIONS: Sugammadex could reverse rocuronium-induced neuromuscular blockade in a dose-response manner even in the patients treated with magnesium sulfate.

[Effects of magnesium on the onset time of rocuronium in patients for cesarean delivery].

BACKGROUND: Although magnesium can potentially shorten onset time of a muscle relaxant, it is unclear whether it does shorten the onset time of rocuronium for patients in cesarean delivery (CD). Thus the purpose of this study is to compare the onset time of rocuronium in patients with or without preoperative magnesium treatment. METHODS: In 9 CD patients without magnesium (CD group) and 8 CD patients with magnesium (CD-Mg group), neuromuscular function was continuously assessed with acceleromyography immediately after induction of general anesthesia with intravenous injection of thiopental (4-5 mg x kg(-1)) and rocuronium (0.6 mg x kg(-1)). Onset time of muscle relaxation, defined by the time from rocuronium bolus injection until complete absence of twitch height, was measured. RESULTS: The onset time of both groups did not significantly differ (50 +/- 10 seconds vs. 51 +/- 11 seconds; P = 0.93, unpaired t-test). Median magnesium concentration, 5.2 mg x dl(-1) (3.8-6.3), and the onset time of CD-Mg group did not correlate magnesium concentrations (P = 0.23, Pearson's correlation coefficient test). CONCLUSIONS: Magnesium did not shorten the onset time of rocuronium 0.6 mg x kg(-1) in CD patients.

[Effects of pregnancy on the onset time of rocuronium].

BACKGROUND: Rapid onset of a muscle relaxant is required for general anesthesia with rapid sequence induction technique. Although a high dose of rocuronium was demonstrated to achieve the rapid onset in non-pregnant persons, it is still unknown whether this is true in women during late pregnancy. The purpose of this study is to compare the onset time of high dose rocuronium between pregnant and non-pregnant women. METHODS: Ten pregnant women undergoing cesarean delivery and 10 age, height, and body weight-matched non-pregnant women were enrolled in the study. Neuromuscular function was continuously assessed by twitch response with acceleromyography immediately after induction of general anesthesia with intravenous injection of thiopental (4-5 mg x kg(-1)) and rocuronium (0.9 mg x kg(-1)). Onset time of muscle relaxation, defined by the time from rocuronium bolus injection to complete absence of twitch height, was measured. RESULTS: The onset time of rocuronium in pregnant women was significantly shorter than that in non-pregnant women (42 +/- 9 seconds vs. 56 +/- 10 seconds; P = 0.0039. unpaired t-test). CONCLUSIONS: The onset time of high dose of rocuronium in pregnant women was significantly shorter than that of non-pregnant women.

[Ultrasound assessment of gastric content in cesarean delivery patients: an observational study].

BACKGROUND: The aim of this observational study is to examine the benefit of ultrasound assessment of gastric content in cesarean delivery (CD) patients. METHODS: Thirty-nine patients scheduled for CD were assigned to a scheduled CD group and to an emergency group. Before CD, gastric ultrasonography examinations to calculate CSA (cross sectional area) of gastric antrum were performed to determine if gastric content was residual, and patients in the emergency group were asked what and when they had eaten. They were classified as full stomach when CSA was 2.5 cm2 or more and the sonographic characteristics of the antrum showed mixture with high echogenic particles. RESULTS: Eight patients were assigned to a scheduled CD group and thirty-one patients to an emergency group, respectively. None of the scheduled CD group should be CSA of 2.5 cm2 or more and eight of the emergency group should be 2.5 cm2 or more, including 3 patients with or without labor showing residual gastric contents after more than 10 hours of ingestion. CONCLUSIONS: There are some CD patients with the high risk of aspiration with or without labor even 10 hours after the last ingestion.

Sudden glottic stenosis caused by cricoarytenoid joint involvement due to rheumatoid arthritis.

A woman with rheumatoid arthritis (RA) experienced glottic stenosis approximately two months after switching from etanercept to tocilizumab. Cricoarytenoid joint (CAJ) arthritis due to RA was diagnosed. An awake tracheostomy saved the relievable airway, and the administration of methylprednisolone and infliximab ameliorated the flare-up and glottic stenosis. A follow-up examination revealed the recovery of the patient's normal voice and good control of RA with infliximab and methotrexate. Although general physicians do not frequently encounter patients with symptomatic CAJ arthritis, this condition should be considered as it can be life-threatening. Therefore, when detected, it should be diagnosed and treated immediately.

[Efficacy of ultrasound imaging of lumbar epidural anesthesia in patients for cesarean delivery: A comparative study between longitudinal and transverse plane imaging].

BACKGROUND: It has been demonstrated that preparatory ultrasound scanning can facilitate lumbar epidural anesthesia. We compared longitudinal with transverse approach of ultrasound imaging to test the precision and the quality of acquired images in cesar ean delivery patients. METHODS: We enrolled 34 cesarean delivery patients. Measured distances from the skin to dura on each ultrasound view was compared with the actual needle depth. Additionally we measured ultrasound visibility score. RESULTS: The both distances measured in ultrasound strongly correlated with the actual depth (R2= 0.87 and 95% limits of agreement of -3.07 to 6.45 mm on longitudinal view, R2=0.82 and 95% limits of agreement of -3.50 to 7.74 mm on longitudinal view). The visibility score of the longitudinal view was significantly higher than that of transverse view (P<0.01). CONCLUSIONS: Both planes provided accurate information about the epidural space and depth, and the longitudinal plane was superior in the imaging quality. It was suggested that both approaches may help identify epidural spaces.

[Safe practice of oral rehydration therapy by oral rehydration solution and carbohydrate loading--evaluation by non-invasive gastric echo examination].

Many anesthesiologists are reluctant to depart from their traditional long fasting periods, even though many guidelines recommend that oral intake of clear fluids administered up to 2-3 hours prior to general anesthesia does not adversely affect the gastric contents. It also indicates that the application of these guidelines does not affect the incidence of pulmonary aspiration. One of the reasons why they have not changed their practices is that they wonder whether it is safe to administer clear fluids as recommended in the guidelines. In this review, we emphasize that oral rehydration therapy using clear fluids (such as OS-1, water and carbohydrate-rich beverage) is safe based on the non-invasive gastric echo examinations as many guidelines have already indicated. Oral rehydration therapy should be considered not only as an alternative to intravenous therapy for preoperative fluid and electrolyte management but also as one of the important modalities which can enhance the recovery of surgical patients.

[Safety of preoperative oral rehydration therapy].

BACKGROUND: OS-1 is an oral rehydration solution that conforms with the principles of oral rehydration therapy. It may be useful for preoperative fluid management of surgical patients. While intake of clear fluids 2 hours before surgery is considered safe, it is not known if the same applies to OS-1. We therefore investigated the safety of OS-1 for preoperative patients as compared with clear fluids. METHODS: First, eight healthy adult volunteers were studied in a crossover manner. Volunteers ingested 500 ml of OS-1 or water (clear fluid). Gastric emptying time was measured using gastric ultrasonography. Gastric antral area as measured by ultrasonography correlates well with gastric volume in a close-to-linear manner. Next, we measured gastric volume of elective surgical patients who had drunk OS-1 until two hours before the induction of anesthesia. RESULTS: Gastric emptying time did not differ between OS-1 and water. The stomach was emptied 30 minutes after ingestion of both OS-1 and water. The fasting stomach was identified in all patients who had drunk OS-1 before surgery. CONCLUSIONS: We concluded that allowing elective surgical patients to drink OS-1 until two hours before anesthesia did not affect the volume of gastric contents.

[Case of emergent caesarean delivery in a patient with aplastic anemia complicated with pregnant induced hypertension].

A 32-year-old pregnant woman diagnosed with aplastic anemia was admitted for emergent caesarean delivery of 26th week of the gestation due to PIH (pregnancy-induced hypertension) and NRFS (non-reassuring fetal status). After compensating platelets counts to 5.3x10(4) microl-1, general anesthesia was induced with propofol and rocuronium. Anesthesia was maintained with O2 and sevoflurane until delivery and with modified-NLA after delivery. She was additionally monitored with Vigileo/FloTrac system (Edwards Lifesciences, USA) and TOF-WATCH SX (Nihon Kohden, Tokyo). After 8 minutes of operation her baby was born with the 5-minute Apgar score of 5 and the UA-pH of 7.387. It was only 2 hours and 12 minutes that the baby was born after she was admitted. The baby was tracheally intubated and transferred to NICU. Blood loss during operation was 835 g and two units of RCC was transfused. Circulatory values were kept acceptable and neuromuscular blocking was completely reversed by sugammadex and extubated in the operating room. Bleeding tendency and atonic bleeding were not observed. She survived perioperative period and was to be treated for aplastic anemia. Her baby was discharged neurologically free. We should be ready to respond to anesthetic requirement for urgent cases of aplastic anemia.

[Hemodynamic changes during pregnancy and cesarean delivery in three cases of triplet pregnancy].

Polypregnancy is one of the major problems to both mothers and fetuses leading to poor prognosis. Even though hemodynamic parameters change greatly during pregnancy and cesarean delivery, it is unclear how blood volume (BV) and cardiac output (CO) increase during triplet pregnancy and how CO goes up and down during cesarean delivery in the cases of triplet pregnancy. We measured BV and CO by dye-densitogram analyzer (DDG-analyzer: Nihon Kohden, Tokyo, Japan) and CO by FlowTrac (Edwards Lifesciences, Irvine, USA) on three cases of triplet pregnancy. BV increased up to about 50% above that of singleton after 20 weeks of gestational age. However, there was no such tendency in CO. When they underwent cesarean delivery under combined spinal-epidural anesthesia (CSEA) or sequential-CSE (S-CSE) receiving a 10 or 12 mg intrathecal isobaric bupivacaine with 20 microg fentanyl, CO decreased in parallel with blood pressure from ten minutes after spinal anesthesia, to the start of operation and just after the birth of third fetus.

[Simulation of obstetrical disseminated intravascular coagulation (DIC) by scoring algorithm criteria established by the Japanese Association for Acute Medicine, the revised Japanese Ministry of Health and Welfare criteria and the International Society on Thrombosis and Haemostasis criteria].

BACKGROUND: Although obstetric disease is one of the major causes of disseminated intravascular coagulation (DIC), no gold standard exists. Three current criteria, the Japanese Association for Acute Medicine (JAAM) -DIC criteria, the revised Japanese Ministry of Health and Welfare (JMHW) criteria and the International Society on Thrombosis and Haemostasis (ISTH) criteria, do not clarify the usefulness in obstetric DIC. We therefore conducted a retrospective study by simulation. METHODS: We enrolled 89 cases of emergent caesarean section when platelet count decreased to below 150,000 x 10(9) x mm(-3) during 7 days from 3 days before operation to 3 days after operation from April 2004 to March 2007. We applied them and compared diagnostic rates and investigated characteristics of obstetric DIC. RESULTS: After excluding 21 cases, 68 cases were examined. The number of patients diagnosed with DIC by JAAM-DIC criteria, JMHW criteria and ISTH criteria were 15 (22.1%), 5 (7.4%) and 3 (4.4%), respectively. Fifteen patients who fulfilled JAAM-DIC criteria included all 5 patients for whom DIC was diagnosed by JMHW criteria, and those 5 patients included all 3 patients for whom DIC was diagnosed by ISTH criteria. CONCLUSIONS: The current study indicates that JAAM-DIC criteria can be useful but may overdiagnose the DIC.

[Perioperative management of a patient with subarachnoid hemorrhage complicated with descending aortic dissection].

A 62-year-old man with descending aortic dissection received general anesthesia for clipping of aneurysm of the cerebral artery. We chose a surgical operation for the aneurysm of the cerebral artery, and conservative therapy for the dissection of the aorta. We gave balanced anesthesia with blood pressure control using calcium channel blocker. Anesthesia was induced with propofol, fentanyl, and vecuronium, and maintained with isoflurane, fentanyl, nitrous oxide and oxygen. Transesophageal echocardiography was useful for checking dissection of the aorta. Perioperative course was uneventful.