The Perioperative Frontal Relative Ratio of the Alpha Power of Electroencephalography for Predicting Postoperative Delirium After Highly Invasive Surgery: A Prospective Observational Study.

BACKGROUND: We investigated the associations between postoperative delirium (POD) and both the relative ratio of the alpha (α)-power of electroencephalography (EEG) and inflammatory markers in a prospective, single-center observational study. METHODS: We enrolled 84 patients who underwent radical cancer surgeries with reconstruction for esophageal cancer, oral floor cancer, or pharyngeal cancer under total intravenous anesthesia. We collected the perioperative EEG data and the perioperative data of the inflammatory markers, including neutrophil gelatinase-associated lipocalin, presepsin, procalcitonin, C-reactive protein, and the neutrophil-lymphocyte ratio (NLR). The existence of POD was evaluated based on the Intensive Care Delirium Screening Checklist. We compared the time-dependent changes in the relative ratio of the EEG α-power and inflammatory markers between the patients with and without POD. RESULTS: Four of the 84 patients were excluded from the analysis. Of the remaining 80 patients, 25 developed POD and the other 55 did not. The relative ratio of the α-power at baseline was significantly lower in the POD group than the non-POD group (0.18 ± 0.08 vs 0.28 ± 0.11, P < .001). A time-dependent decline in the relative ratio of α-power in the EEG during surgery was observed in both groups. There were significant differences between the POD and non-POD groups in the baseline, 3-h, 6-h, and 9-h values of the relative ratio of α-power. The preoperative NLR of the POD group was significantly higher than that of the non-POD group (2.88 ± 1.04 vs 2.22 ± 1.00, P < .001), but other intraoperative inflammatory markers were comparable between the groups. Two multivariable logistic regression models demonstrated that the relative ratio of the α-power at baseline was significantly associated with POD. CONCLUSIONS: Intraoperative frontal relative ratios of the α-power of EEG were associated with POD in patients who underwent radical cancer surgery. Intraoperative EEG monitoring could be a simple and more useful tool for predicting the development of postoperative delirium than measuring perioperative acute inflammatory markers. A lower relative ratio of α-power might be an effective marker for vulnerability of brain and ultimately for the development of POD.

Association between regional oxygen saturation and central venous saturation in pediatric patients undergoing cardiac surgery: A prospective observational study.

BACKGROUND: We evaluated the correlation between regional oxygen saturation (rSO2 ) in the frontal and right renal dorsum (cerebral rSO2 and somatic rSO2 ) measured by near-infrared spectroscopy (INVOS™ 5100C, Medtronic) and central venous oxygen saturation (ScvO2 ) measured with a fiber-optic oximetry catheter (PediaSat™, Edwards Lifesciences) during surgery in order to determine whether noninvasive rSO2 could be used as an alternative to ScvO2 in pediatric cardiac surgery patients. We evaluated the correlation between regional tissue oxygen saturation (cerebral rSO2 and somatic rSO2 ) measured by near-infrared spectroscopy and other patient measures with central venous oxygen saturation (ScvO2 ) measured with a fiber-optic oximetry catheter to track global oxygen supply demand as a potential alternative or supplement to ScvO2 . PATIENTS AND METHODS: This single-center prospective observational study enrolled 33 children (weight < 10 kg) who underwent cardiac surgery for congenital heart disease between February 2018 and November 2021. ScvO2 , cerebral rSO2 , and somatic rSO2 were recorded simultaneously after anesthesia induction and central venous catheter placement. Pearson's correlation coefficient and Bland-Altman analysis were used to determine the relationship between ScvO2 and rSO2 . We conducted correlation, Bland Altman, and multiple regression analyses to identify associations between rSO2 , patient measures, and ScvO2 values. RESULTS: The patients' median age was 11.0 (quartile 2.0-16.0) months. Their weight was 7.2 (quartile 4.5-9.2) kg. Cerebral rSO2 was significantly positively correlated with ScvO2 (r2 = 0.29, p = .002 in all patients; r2 = 0.61, p = .013 in the patients without mixing at the atrial level), whereas somatic rSO2 was not. The Bland-Altman analysis demonstrated biases [95% confidence interval; 95% CI] (lower and upper limits of agreement [95% CI]) of 0.27% [-4.26 to 4.80] (-24.79 [-32.61 to -16.96] to 25.33 [17.50 to 33.16]) between cerebral rSO2 and ScvO2 and 0.91% [-5.48 to 7.30] (-34.43 [-45.47 to -23.39] to 36.25 [25.21 to 47.29]) between somatic rSO2 and ScvO2 . Preoperative brain natriuretic peptide (BNP) and SpO2 were independent variables associated with ScvO2 and cerebral and somatic rSO2 . CONCLUSION: Cerebral rSO2 , SpO2 , and BNP were significantly correlated with ScvO2 , although the cerebral rSO2 correlation was greater for lesions without atrial mixing. rSO2 , BNP, and SpO2 might be used to track changes in ScvO2 but cerebral rSO2 is not sufficiently precise to replace it.

Preoperative cerebral and renal oxygen saturation and clinical outcomes in pediatric patients with congenital heart disease.

We examined the predictability of preoperative cerebral and renal rSO2 values for outcomes in pediatric patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Patients who underwent pediatric cardiac surgery under CPB between September 2015 and September 2017 were enrolled in this study. Patients monitored with both cerebral and renal rSO2 at the beginning of surgery were included. The primary outcome was the prediction of outcomes after pediatric cardiac surgery. Outcome was defined as any of: (1) death within 30 days after surgery, or the need for (2) renal replacement therapy or (3) extracorporeal membrane oxygenation, (4) shorten mechanical ventilator-free day,(5) shorten ICU-free survival day. We included 59 patients: cyanotic n = 31; non-cyanotic n = 28. Among all patients, 15 (25%) had poor outcomes, including three deaths. The cerebral and renal rSO2 values were significantly lower in the cyanotic patients with poor outcomes compared to those without poor outcomes (cerebral: 59 ± 11 vs. 50 ± 5, p = 0.021; renal: 59 ± 15 vs. 51 ± 14, p = 0.015) but only the renal rSO2 value was significantly lower in the non-cyanotic patients (77 ± 10 vs. 61 ± 14, p = 0.011). The cut-off value (51%) of cerebral rSO2 were associated with risk of mechanical ventilator-free day and ICU-free survival day [ORs of 22.8 (95% CI 2.21-235.0, p = 0.0087) and 15.8 (95% CI 1.53-164.0, p = 0.0204), respectively] in the cyanotic patients. The cut-off value (66%) of cerebral rSO2 value was associated with risk of mechanical ventilator-free day [OR of 11.3 (95% CI 1.05-25.3, p = 0.0456)] and the cut-off value (66%) of renal rSO2 value was associated with risk of ICU-free survival day [ORs of 33.0 (95% CI 2.25-484.0, p = 0.0107)] in the noncyanotic patients. The preoperative low rSO2 values were associated with outcomes including 30-day mortality and might be reflective of the severity of cardiopulmonary function. Further studies are needed to confirm our results.

Pilot Study of Changes in Presepsin Concentrations Compared With Changes in Procalcitonin and C-Reactive Protein Concentrations After Cardiovascular Surgery.

OBJECTIVE: The authors investigated the presepsin-concentration profile after cardiac surgery compared with those of procalcitonin (PCT) and C-reactive protein (CRP). DESIGN: A single-center, prospective, observational clinical study. SETTING: Hirosaki University Hospital. PARTICIPANTS: Patients who underwent cardiovascular surgery without preoperative infection and end-stage kidney disease requiring dialysis. The patients also were subdivided into 2 groups with respect to the use of cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: Presepsin, PCT, and CRP were measured 4 times: before the induction of anesthesia (baseline), postoperative day (POD) 0, POD 1, and POD 2. Data are expressed as median (25th, 75th interquartiles). A total of 33 patients were examined: 22 patients with CPB and 11 without CPB. For the entire patient series, the presepsin concentrations on POD 0 (220 [166-445] pg/mL), POD 1 (328 [210-581] pg/mL), and POD 2 (310 [202-368] pg/mL) were increased significantly (p < 0.05) compared with baseline (176 [123-275] pg/mL). The PCT and CRP concentrations on POD 1 (0.57 [0.27-1.29] ng/mL and 5.4 [3.1-8.8] mg/dL) and POD 2 (0.64 [0.33-1.43] ng/mL and 11.8 [4.4-17.0] mg/dL) also were increased significantly (p < 0.05) compared with baseline (0.04 [0.03-0.06] ng/mL and 0.07 [0.03-0.22] mg/dL). However, the median concentrations of presepsin up to POD 2 were less than the reported cut-off value (600 pg/mL) to detect infections, whereas those of PCT were above the reported cut-off value (0.5 ng/mL). The increases in presepsin and PCT concentrations were independent of the use of CPB. CONCLUSIONS: Cardiovascular surgery significantly increased presepsin concentrations, earlier than PCT and CRP.

Effects of cardiac output on the initial distribution volume of glucose in the absence of fluid gain or loss in pigs.

The initial distribution volume of glucose (IDVG) has been reported to be a surrogate marker of cardiac preload. However, the relationship between cardiac output and IDVG is not fully understood. We investigated the effects of cardiac output on IDVG in the absence of fluid gain or loss in pigs. MATERIALS AND METHODS: Thirteen pigs were anesthetized and allocated to either the modified cardiac output group (m-CO group, n = 10) or the control group (control group, n = 3). In the m-CO group, CO was sequentially modulated from high CO (high CO) to two grades of low CO (low CO-1 and low CO-2) with dobutamine and propranolol with lidocaine, respectively, in the absence of any apparent change in basal fluid volume status. Thermodilutional CO and IDVG were measured at each CO condition. The IDVG was measured according to a one-compartment model with 2 g glucose. The same parameters were measured in the control group using the same time schedule as for the m-CO group but without inotropes and at a stable CO state. Thereafter, 250 ml of 10% dextran were infused over 15 min to compare the effects of a preload-dependent increase in CO on IDVG measurements to the effects of the pharmacological modification of CO. Data were expressed as the mean ± SD. Statistical analysis was performed with repeated measures ANOVA followed by Dunnett's test. Pearson's correlation test was also used. A P value of <0.05 was considered to indicate statistical significance. RESULTS: In the m-CO group, where CO increased to 147.2 ± 26.7% of the baseline CO value in the high CO state and decreased to 65.9 ± 11.0 and 37.3 ± 14.4% of the baseline CO value in the low CO-1 state and the low CO-2 state, respectively, the IDVG did not change as CO was modified. IDVG significantly increased in response to volume loading of dextran in the control group. There was no correlation between the IDVG and CO in the m-CO group when there was no fluid gain or loss (r = 0.097, n = 40, P = 0.554), but the IDVG was well correlated with CO in the control group with volume loading (r = 0.764, n = 18, P = 0.0002). CONCLUSION: This study suggests that the IDVG is dependent on the central extracellular fluid volume and not on cardiac output.

Changes in presepsin concentrations in surgical patients with end-stage kidney disease undergoing living kidney transplantation: a pilot study.

Presepsin is a useful marker for differentiating sepsis from non-infection-related systemic inflammatory response syndrome. There are data describing elevated presepsin concentrations in patients with kidney dysfunction even in the absence of sepsis, but corresponding data for patients with end-stage kidney disease (ESKD) undergoing living kidney transplantation (LKT) are lacking. We investigated the changes in presepsin concentrations in this patient group in order to elucidate any relationship with renal function. Written informed consent was obtained from patients with ESKD requiring hemodialysis who underwent LKT from June 2014 through March 2015 at Hirosaki University Hospital. Patients with obvious signs of infection were excluded. Perioperative presepsin and procalcitonin concentrations were measured before induction of anesthesia, on admission to the intensive care unit after surgery, and on postoperative day (POD) 1 and POD 2. Preoperative presepsin concentration was markedly higher than the upper limit of normal in patients with ESKD (1252 ± 451 pg/mL). Presepsin concentrations consistently decreased after LKT. Moreover, presepsin concentration was strongly correlated with serum creatinine (r (2) = 0.72, n = 24, p < 0.001). These data suggest that the kidney clearly plays an important role in the metabolism and excretion of presepsin.

[Observation of the lungs using ultrasonography].

The three ways to observe the lungs using ultrasonography are transthoracic echography, transesophageal echography and endobronchial ultrasonography. All methods have their own advantages. Consolidation and pleural effusion are evaluated with transthoracic echography and transesophageal echography. The advent of comet-tail artifact observation made the transthoracic echography worthwhile.

[Case of Rh (-) patient's right lobectomy of the liver with massive hemorrhage evading allogeneic blood transfusion by hemodilutional autologous blood transfusion].

A 44-year-old man (ASA-PS 1) underwent right lobectomy of the liver under total intravenous anesthesia with propofol, remifentanil, ketamine and rocuronium. In order to evade allogeneic blood transfusion, 1,200 g of the patient's blood was taken and hemodilution was induced for autologous blood transfusion (HAT) after the induction of anesthesia. As intraoperative blood loss amounted to about 4,000 g, Hb level decreased from 13.6 to 6.2 g x dl(-1). However, as intraoperative hemodynamics was relatively stable with crystalloidal and colloidal transfusion with no ischemic change on ECG and no metabolic acidosis, autologous blood transfusion was withheld. After returning the autologous blood, Hb increased to 9.8 g x dl(-1). Any postoperative complications related to the low Hb level were not recognized. HAT is a useful method to evade or at least decrease the amount of allogeneic blood transfusion by anesthesiologists.

Successful Fluid Management in Respiratory Failure due to Clazosentan Following a Cerebral Aneurysm Clipping: A Case Report.

Clazosentan, a potent selective endothelin receptor subtype A antagonist, has been demonstrated to be effective in preventing cerebral vasospasms after subarachnoid hemorrhage. We report the successful management of respiratory failure due to pulmonary edema associated with clazosentan, with a hemodynamic monitoring system. A 49-year-old Japanese man underwent emergency clipping for a right internal carotid-posterior communicating artery aneurysm. The surgery and general anesthesia for the rupture proceeded with no complications. Clazosentan was administered from postoperative day 1 to prevent cerebral vasospasm. He presented with respiratory failure six days post surgery and chest X-ray imaging showed pulmonary edema. In our intensive care unit, the patient's N-terminal pro-brain natriuretic peptide was 476 pg/mL although trans-thoracic echography indicated a normal left ventricular ejection fraction (>60%) and normal diastolic function. The hemodynamic monitoring system showed 11 L/minute cardiac output and a cardiac index of 5.6 L/minute/m2. We thus diagnosed the cause of the patient's respiratory failure as due to excessive volume, as an adverse event of clazosentan. We changed the cerebral vasospasm-preventive drug to fasudil hydrochloride hydrate and forced urination. His body weight dropped approximately 9 kg as of day 9 in the ICU and he was weaned off the ventilator 23 days post surgery. This case indicates the importance of optimal infusion in patients with clazosentan. Optimal fluid management using a hemodynamic monitoring system could be useful for clazosentan-induced respiratory failure.

Corrected right ventricular end-diastolic volume and initial distribution volume of glucose correlate with cardiac output after cardiac surgery.

PURPOSE: Appropriate adjustment of cardiac preload is essential to maintain cardiac output (CO), especially in patients after cardiac surgery. This study was intended to determine whether index of right ventricular end-diastolic volume (RVEDVI), corrected RVEDVI using ejection fraction (cRVEDVI), index of initial distribution volume of glucose (IDVGI), or cardiac filling pressures are correlated with cardiac index (CI) following cardiac surgery in the presence or absence of arrhythmias. METHODS: Eighty-six consecutive cardiac surgical patients were studied. Patients were divided into two groups: the non-arrhythmia (NA) group (n = 72) and the arrhythmia (A) group (n = 14). Three sets of measurements were performed: on admission to the ICU and daily on the first 2 postoperative days. The relationship between each cardiac preload variable and cardiac index (CI) was evaluated. A p value less than 0.05 indicated statistically significant differences. RESULTS: Each studied variable was not different between the two groups immediately after admission to the ICU. cRVEDVI had a linear correlation with CI in both group (NA group: r = 0.67, n = 216, p < 0.001; A group: r = 0.77, n = 42, p < 0.001), but RVEDVI had a poor correlation with CI (NA group: r = 0.27, n = 216, p < 0.001; A group: r = 0.19, n = 42, p = 0.036). IDVGI had a linear correlation with CI (NA group: r = 0.49, n = 216, p < 0.001; A group: r = 0.61, n = 42, p < 0.001), Cardiac filling pressures had no correlation with CI. CONCLUSION: Our results demonstrated that cRVEDVI and IDVGI were correlated with CI in the presence or absence of arrhythmias. cRVEDVI and IDVGI have potential as indirect cardiac preload markers following cardiac surgery.

[A case of hypernatremia treated with human atrial natriuretic peptide].

We describe a case of 65-year-old obese female patient with pulmonary embolism and life-threatening hypernatremia after removal of craniopharyngioma. On the 18th day after neurosurgical procedure, pulmonary embolism developed abruptly. Immediately after placement of inferior vena cava filter, surgical removal of the pulmonary thrombus was performed under cardiopulmonary bypass. Although mechanical ventilatory support and infusion of noradrenaline were required postoperatively, the trachea was extubated on the 10th postoperative day. Meanwhile, daily serum Na level increased gradually and reached 178 mEq x l(-1). We suspected that dehydration and pituitary dysfunction were mainly responsible for the hypernatremia. Human atrial natriuretic peptide (hANP) was infused from the 2nd to the 4th postoperative day, and her urinary Na excretion became increased and serum Na level became normal. After discontinuation of hANP, urinary Na excretion became decreased again and serum Na levels increased transiently. However, her consciousness level and cardiopulmonary condition improved and she was discharged from the ICU after twelve days of ICU stay. HANP may be useful for treatment of life-threatening hypernatremia.

[Case of fluminant myocarditis with fatal pulmonary edema even after introduction of bi-ventricular assist devices].

A 15-year-old man developed cardiopulmonary dysfunction 4 days after flu-like symptom, and was transfered to our hospital and diagnosed as a fulminant myocarditis (FM). Intraaortic ballon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were immediately initiated. However, cardiac function did not recover until 7 days after admission to the ICU, and bilateral ventricular assist devices (BiVAD) were introduced with extracorporeal membrane oxygenation (ECMO). Right ventricular assist device (RVAD) with ECMO was established by right atrial blood withdrawal and pulmonary arterial blood supply using centrifugal pump. After operation of BiVAD, to main LVAD flow, frequent blood-and-fluids volume loading and increase in RVAD flow were necessary due to postoperative bleeding and massive foamy sputum. However, even after hemostasis had been established, the pulmonary edema continued and it was difficult to maintain LVAD flow because of endless transudation from the lungs. Eventually, he developed MOF and passed away 9 days after the admission to ICU. As in cases of end-stage dilated cardiomyopathy, outflow of RVAD into the left atrium instead of the pulmonary artery was demonstrated effective in avoiding trans-pulmonary leakage, and outflow of RVAD into the left atrium may be beneficial to patients with FM who need BiVAD but suffered severe pulmonary edema.

Successful management of a patient with preoperative respiratory failure due to a solid giant retroperitoneal tumor: a case report.

BACKGROUND: We report the successful preoperative management of respiratory failure in a patient with a solid giant retroperitoneal tumor with a hemodynamic monitoring system and nasal high-flow therapy (NHFT). CASE PRESENTATION: Twenty days before his scheduled resection of a giant retroperitoneal liposarcoma, a 64-year-old man presented with dyspnea. After admission to our intensive care unit, he received NHFT and hemodynamic therapy using a LiDCOrapid V3™ monitor (Masimo Japan, Tokyo). NHFT and intense diuresis improved his respiratory condition. The tumor resection was performed on the 5th day. He was discharged to the general ward with an oxygen nasal cannula on the second postoperative day. Although preoperative transthoracic echography showed mild aortic regurgitation and moderate mitral regurgitation, the degree of regurgitation had become trivial about 1-month post-surgery. CONCLUSIONS: A cause of preoperative respiratory failure associated with a giant retroperitoneal tumor might be not only diaphragmatic compression but also heart failure and excess fluid volume.

Drastic improvement of cardiac function after living-donor renal transplantation in a long-term hemodialysis patient with severe mitral regurgitation.

BACKGROUND: Although there are reports of recovery of cardiac function after renal transplantation, the feasibility of renal transplantation in patients with low cardiac function remains controversial. CASE PRESENTATION: A 59-year-old Japanese male was scheduled to undergo living-donor renal transplantation (LDRT) under general anesthesia. Preoperative transthoracic echocardiography revealed severe mitral regurgitation (MR) and a left ventricular ejection fraction (LVEF) at 30%. LDRT was conducted prior to cardiac surgery with restrictive fluid management and close monitoring of cardiac function. The patient's renal function improved promptly after the LDRT, and his hemodynamics were stable throughout the perioperative period. Along with improvements in the patient's renal function and anemia, the patient's cardiac function improved to LVEF 50% and achieved drastically improved MR as well as cardiac function, without intervention. CONCLUSION: This case indicates that LDRT has the potential to improve cardiac function in patients who have been on hemodialysis for more than 20 years.

Predict models for prolonged ICU stay using APACHE II, APACHE III and SAPS II scores: A Japanese multicenter retrospective cohort study.

Prolonged ICU stays are associated with high costs and increased mortality. Thus, early prediction of such stays would help clinicians to plan initial interventions, which could lead to efficient utilization of ICU resources. The aim of this study was to develop models for predicting prolonged stays in Japanese ICUs using APACHE II, APACHE III and SAPS II scores. In this multicenter retrospective cohort study, we analyzed the cases of 85,558 patients registered in the Japanese Intensive care Patient Database between 2015 and 2019. Prolonged ICU stay was defined as an ICU stay of >14 days. Multivariable logistic regression analyses were performed to develop three predictive models for prolonged ICU stay using APACHE II, APACHE III and SAPS II scores, respectively. After exclusions, 79,620 patients were analyzed, 2,364 of whom (2.97%) experienced prolonged ICU stays. Multivariable logistic regression analyses showed that severity scores, BMI, MET/RRT, postresuscitation, readmission, length of stay before ICU admission, and diagnosis at ICU admission were significantly associated with higher risk of prolonged ICU stay in all models. The present study developed predictive models for prolonged ICU stay using severity scores. These models may be helpful for efficient utilization of ICU resources.

Plasma orexin A does not reflect severity of illness in the intensive care units patients with systemic inflammation.

BACKGROUND: Systemic inflammatory response occurs by sepsis and invasive surgery. Recent articles suggest that not only CRP but also procalcitonin, presepsin, and neutrophil gelatinase-associated lipocalin may reflect the severity of systemic inflammation. In addition, as systemic inflammation could degenerate orexin neurons, plasma orexin A might also be a good biomarker to predict the severity. Thus, we have determined relation between plasma biomarker and severity of illness score in patients with systemic inflammation. METHODS: Previous database (UMIN000018427) was used to secondly determine which plasma biomarkers may predict the severity of illness in the ICU patients with systemic inflammation (n = 57, 31 non-sepsis surgical patients and 26 sepsis patients). We measured plasma levels of orexin A, CRP, procalcitonin, presepsin, and neutrophil gelatinase-associated lipocalin were measured, and APACHE II score was assessed in these patients at their admission to the ICU. Data are shown as mean ± SD. Statistical analyses were done with unpaired t test. The correlation between APACHE II score and plasma biomarkers were examined using Pearson's correlation coefficient and a least squares linear regression line. RESULTS: Demographic data did not differ between sepsis and non-sepsis groups. However, APACHE-II score was significantly higher in sepsis group than those in non-sepsis group (20.9 ± 6.6 vs 15.8 ± 3.2, p < 0.01). There were significant correlations between APACHE II score and plasma CRP (r = 0.532, p < 0.01), procalcitonin (r = 0.551, p < 0.01), presepsin (r = 0.510, p < 0.01), and neutrophil gelatinase-associated lipocalin (r = 0.466, P < 0.01) except orexin A. CONCLUSION: All plasma biomarkers tested except orexin A may reflect the severity of illness in patients with systemic inflammation.

Anesthetic management with remimazolam in a patient with Child-Pugh C liver cirrhosis: a case report.

BACKGROUND: Remimazolam is a new ultra-short-acting benzodiazepine, and its sedative effect is prolonged in patients with hepatic impairment. This is the first report of remimazolam anesthesia in a patient with Child-Pugh C liver cirrhosis. CASE PRESENTATION: A 52-year-old female was diagnosed with tongue cancer and scheduled for partial glossectomy. Preoperative examinations revealed Child-Pugh C liver cirrhosis, but the pathogenesis was unknown. We scheduled remimazolam anesthesia because it would stabilize her intraoperative circulation. We managed with a much lower-than-normal dose of remimazolam; even so, the patient required flumazenil to regain consciousness. She was admitted to the intensive care unit, but her consciousness remained clear even after the effect of flumazenil had worn off. CONCLUSION: We experienced anesthetic management with remimazolam in a patient with Child-Pugh C liver cirrhosis. Even conservative use of remimazolam in patients with severe hepatic dysfunction may result in emergence times that are delayed longer than expected.

Bedside insertion of a peripherally inserted central catheter into a patient with BMI of 84.8 kg/m2 using a magnetic tracking and electrocardiogram-based tip confirmation system: a case report.

BACKGROUND: Peripherally inserted central catheters (PICCs) are typically placed under fluoroscopy. We used a magnetic tracking and electrocardiogram-based tip confirmation system for insertion of a PICC insertion in a morbidly obese patient at the bedside. CASE PRESENTATION: A 53-year-old female with severe obesity (height, 160 cm; weight, 217 kg; BMI, 84.8 kg/m2) was admitted to the intensive care unit. Both bilateral, inguinal, and cervical regions were covered with an excess of adipose tissue, making it difficult to place a central venous line. Since transferring her to fluoroscopy seemed dangerous, a PICC was inserted using Sherlock 3CG® TCS at the bedside. Magnetic sensor guidance failed due to the thick subcutaneous tissue her precordium, but intracavity electrocardiography could direct the tip to an appropriate position. CONCLUSION: We experienced bedside insertion of a PICC into a patient with BMI of 84.8 kg/m2 patient using a Sherlock 3CG® TCS. Since the interaction between Sherlock 3CG® TCS and body habitus has not been investigated, further reports are needed.