[Prevention of Postoperative Delirium and Agitation in a Patient with Anti-NMDA Receptor Encephalitis: A Case Report].

A 41-year-old woman with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, characterized by vari- ous psychiatric disturbances, was scheduled for laparo- scopic salpingo-oophorectomy. Anesthesia was induced with fentanyl, propofol and rocuronium, and maintained with intravenous propofol combined with epidural anesthesia (T10-11). The patient received 20 mEq of MgSO4 after induction. MgSO4 administrations were repeated at the end of surgery and every 12 hours for 48 hours after the operation. The operation was per- formed successfully, without any troubles. Trachea was extubated in the operating room. The cognitive dys- function was not observed postoperatively. There was no complication and no unexpected event postopera- tively. One month after surgery, the patient's clinical symptom began to improve. The resection of tumor is recommended as a thera- peutic treatment ; however, there has been few report of the management of postoperative cognitive dysfunc- tion for patients with NMDA receptor antibodies. These patients were more likely to experience a post- operative cognitive dysfunction associated with a poor outcome. We, therefore, administered magnesium sul- fate, NMDA antagonist to prevent postoperative delir- ium. In the present case, magnesium sulfate might have prevented the incidence of postoperative delirium without any complications. The prophylactic magne- sium administration could prevent postoperative delir- ium and agitation safely.

Ventilator-associated pneumonia risk decreased by use of oral moisture gel in oral health care.

Although oral health care has a preventive effect against ventilator-associated pneumonia (VAP), the most effective method of oral health care in this respect remains to be established. The objective of this single-center, randomized, controlled trial was to investigate the relationship between VAP and various methods of oral health care. All patients included in the study (n=142) were on mechanical ventilation with oral intubation at the intensive care unit of the Tokyo Dental College Ichikawa General Hospital. They were divided into two groups, one receiving standard oral health care (Standard group), and the other receiving oral health care using an oral moisture gel instead of water (Gel group). After removal of the intubation tube, biofilm on cuff of the tube was stained with a disclosing agent to determine the contamination level. Factors investigated included sex, age, number of remaining teeth, intubation time, fever ≥38.5°C, VAP, cuff contamination level, and time required for one oral health care session. No VAP occurred in either group during the study period. The level of cuff contamination was significantly lower in the Gel group than the Standard group, and the time required for one session of oral health care was shorter (p<0.001). Multivariate analysis revealed use of the oral moisture gel as a factor affecting cuff contamination level. Use of an oral moisture gel decreased invasion of the pharynx by bacteria and contaminants together with biofilm formation on the intubation tube cuff. These results suggest that oral health care using an oral moisture gel is effective in preventing cuff contamination.

[Comparison of the efficacy of ropivacaine and that of levobupivacaine for postoperative epidural analgesia in patients undergoing gynecological open abdominal surgery].

BACKGROUND: Postoperative analgesia is important in patients undergoing open abdominal surgery. We prospectively compared the efficacy of ropivacaine and that of levobupivacaine for postoperative epidural analgesia in patients undergoing gynecological open abdominal surgery. METHODS: Fifty-two ASA 1-2 patients scheduled for gynecological open abdominal surgery under combined general and epidural anesthesia were enrolled and randomized into two groups. In ropivacaine group (n = 26) the patients received 0.187% ropivacaine and fentanyl 3.2 microg x ml(-1) for postoperative epidural analgesia. In levobupivacaine group (n = 26) the patients received 0.187% levobupivacaine and fentanyl 3.2 microg ml(-1). Visual analogue scale (resting pain and pain on mobilization), the amount of rescue analgesics and epidural anesthesia related adverse events such as hypotension, nausea and vomiting were observed for 48 hours after surgery. RESULTS: There were no differences in visual analogue scale at all intervals between the two groups. In levobupivacaine group the patients used less amounts of rescue analgesics than ropivacaine group (P = 0.01). There were no differences in the incidences of postoperative hypotension, nausea and vomiting between the two groups. CONCLUSIONS: Both 0.187% ropivacaine and levobupivacaine similarly provide appropriate postoperative epidural analgesia for patients undergoing gynecological open abdominal surgery.

The utility of bispectral index monitoring for sedated patients treated with low-dose remifentanil.

The aim of the present study was to determine the effect of low-dose remifentanil on the monitoring quality of the Bispectral index for mechanically ventilated patients. Twelve patients who underwent elective surgery and required mechanical ventilation post-operatively were enrolled in this study with written informed consent. Eligible patients were divided into two groups. Patients in the remifentanil group received low-dose remifentanil (0.05-0.125 µg/kg/min) and propofol (1-3 mg/kg/h). Patients in the control group received propofol (1-3 mg/kg/h). Levels of sedation were evaluated by both the Richmond Agitation Sedation Scale (RASS) and BIS monitor (A2000-XP, version 4.0, Aspect Medical Systems, Newton, USA). Monitoring quality was assessed by a correlation between RASS and BIS values. These values were assessed by single regression analysis and a P value of <0.05 was considered significant. There was a significant correlation between RASS and BIS values (P = 3 × 10(-12), R (2) = 0.67) in the remifentanil group, but not in the control group (P = 0.50, R (2) = 0.057). The administration of low-dose remifentanil makes BIS a more precise tool for sedated patients under mechanical ventilation in the ICU.

[Patient whose surgery was postponed due to complete atrioventricular block on arrival at operating theater].

An 86-year-old woman with low cardiac function was scheduled to undergo hip fracture surgery. Preoperative electrocardiogram showed complete left bundle brunch block, first degree atrioventricular block, left axis deviation and bigeminy. However, her electrocardiogram had changed to complete atrioventricular block on arrival at operating theater. ACC/AHA guideline on perioperative cardiovascular evaluation and care for non cardiac surgery indicates the assessment of both the urgency of the surgery and cardiac complications. Because complete atrioventricular block is classified to "active cardiac conditions", we decided to postpone the surgery for more detailed evaluation and treatment of cardiac conditions. In spite of the discontinuation of digoxin and carvegilol, complete atrioventricular block continued for a week, and the permanent pacemaker was inserted. The surgery was performed 2 weeks following the insertion of the pacemaker without any problems under combined general and lumbar epidural anesthesia.

[An anesthetic case of a patient with multiple sclerosis and supranuclear palsy].

A 60-year-old female with multiple sclerosis (MS) and supranuclear palsy (PSP) was scheduled for right eye iridotomy, left eye phaco emulcification aspiration and insertion of the intraocular lens. Her medical conditions included prolonged immobility, spastic contracture, and a history of convulsion. She was administered with L-dopa, tizanidine, bacrofen, and dantrorane. Anesthesia was induced with propofol 50 mg and fentanyl 25 microg intravenously, and inhalation of oxygen and 1% sevoflurane. Tracheal intubation was performed without neuromuscular blocking agents. Anesthesia was maintained with inhalation of oxygen-air (Fi(O2) 0.4) and 1-1.5% sevoflurane, combined with regional anesthesia. Supplemental fentanyl was administered as needed. The bispectral index (BIS) was monitored and kept between 40 and 60. The operation proceeded uneventfully. After discontinuation of anesthetic agents, she awoke immediately and the BIS index returned to the pre-induction level. Neither neurological disturbances nor unexpected event were observed postoperatively. In patients with MS, it is important to remember the possibility of drugs moving into the central nervou system easily due to the disturbance of the blood-brai barrier. Patients with PSP are usually medicated wit. various medicines which have possibility of interactin with anesthetics. Therefore, we used least anesthetic as possible. In this case, monitoring of BIS seemed to be useful to maintain the minimum sevoflurane concen trations needed.

Recurrent aspiration pneumonia due to bilateral associated laryngeal paralysis after tooth extraction under general anesthesia: a case report.

BACKGROUND: Associated laryngeal paralysis is a clinical condition merged with other cranial nerve disorders associated with vocal cord paralysis. It is a rare complication in patients after general anesthesia. Here, we report our experience with a patient who developed associated laryngeal paralysis after oral surgery. CASE PRESENTATION: A healthy 31-year-old man underwent extraction of horizontally impacted wisdom teeth in the bilateral mandible under general anesthesia. During the surgery, no significant changes in respiratory and cardiovascular parameters or neurosurgical abnormalities occurred. After the surgery, the patient was diagnosed with aspiration pneumonia. Furthermore, the results of otorhinolaryngological and neurological examinations led to a diagnosis of a combination of bilateral glossopharyngeal and vagus nerve paralysis, right recurrent nerve paralysis, and right hypoglossal nerve paralysis. In this case, seriously associated peripheral laryngeal paralysis with repeated episodes of aspiration pneumonia improved in approximately 6 months with rehabilitation and vitamin B12 administration, and no complications remained. CONCLUSIONS: We suggest that the anesthesiologist should take care of each procedure minutely. It is important to diagnose cases of nerve palsy as soon as possible to reduce the damage. Having had experience with this case, we believe sharing our experience with anesthesiologists is important.

Tumor necrosis factor-alpha mediates hyperglycemia-augmented gut barrier dysfunction in endotoxemia.

OBJECTIVE: To examine whether hyperglycemia would augment gut barrier dysfunction and inflammatory responses in endotoxemic rats, and simultaneously to clarify the roles of tumor necrosis factor (TNF)-alpha in alterations of gut mucosal permeability associated with hyperglycemia. DESIGN: Prospective randomized animal study. SETTING: University research laboratory. SUBJECTS: : Male Wistar rats treated with lipopolysaccharide (LPS) injection. INTERVENTIONS: After LPS injection (4 mg/kg), rats were randomly allocated into group S (n = 6), group G (n = 7), or group GI (n = 8) with continuous infusion of different fluid solutions: normal saline, 40% glucose or 10% glucose mixed with insulin, respectively. Blood glucose, insulin, and proinflammatory cytokines, accompanied by gut mucosal permeability using an in situ loop preparation of gut with fluorescence isothiocyanate-conjugated dextran, were measured. Bacterial growth or alterations in mesenteric lymph nodes and cecal contents were also assessed. We further determined the roles of TNF-alpha using an inhibitor of TNF-alpha converting enzyme in gut barrier dysfunction under the same experimental settings. MEASUREMENTS AND MAIN RESULTS: Hyperglycemia over 400 mg/dL was achieved and kept in group G during the study period whereas normoglycemia was preserved in group S and GI, the latter of which showed the similar extent of hyperinsulinemia to group G. Plasma concentrations of fluorescence-labeled dextran and TNF-alpha in group G were significantly higher vs. group S and GI, and the number of bacteria found in mesenteric lymph nodes in group G was greater compared with group S. Intestinal environments including microflora and organic acids were not altered by blood glucose or insulin level. Inhibiting conversion of membrane-bound to soluble type of TNF-alpha restored gut mucosal permeability augmented by hyperglycemia. CONCLUSIONS: These findings indicate that hyperglycemia deteriorates LPS-elicited gut barrier dysfunction and bacterial translocation independently of plasma insulin level, and that TNF-alpha mediates such mucosal dysfunction of gut in endotoxemia.

Improved accuracy of cardiac output estimation by the partial CO2 rebreathing method.

OBJECTIVE: This study investigated the accuracy of the NICO monitor equipped with the newer software. Additionally, the effects of the increased dead space produced by the NICO monitor on ventilatory settings were investigated. METHODS: Forty-two patients undergoing elective aortic reconstruction participated in this prospective, observational study at a university hospital. Cardiac output was continuously monitored using both the NICO monitor and continuous cardiac output (CCO) measured by a pulmonary artery catheter. A NICO monitor equipped with ver. 4.2 software was used for the first 21 patients while a NICO monitor equipped with ver. 5.0 software was used for the rest of the patients. Cardiac output measured by bolus thermodilution (BCO) at 30 min intervals was used as a reference. RESULTS: The bias +/- precision of the NICO monitor was 0.18 +/- 0.88 l/min with ver. 4.2 software (n = 182) and 0.18 +/- 0.83 l/min with 5.0 software (n = 194). The accuracy of the NICO monitor is comparable to CCO, whose bias +/- precision against BCO is 0.19 +/- 0.81 l/min (n = 376). At the same level of CO(2) production and minute ventilation, PaCO(2) was lower in the patients monitored by NICO with ver. 5.0 software than patients with ver. 4.2 software. CONCLUSIONS: This study demonstrated the improved performance of the NICO monitor with updated software. The performance of the NICO monitor with ver. 4.2 or later software is similar to CCO. However, the cardiac output measurement did not fulfill the criteria of interchangeability to the cardiac output measurement by bolus thermodilution. Updates to ver. 5.0 attenuated the effects of rebreathing introduced by the NICO monitor without compromising the accuracy of the cardiac output measurement.

An individualized recruitment maneuver for mechanically ventilated patients after cardiac surgery.

PURPOSE: The recruitment maneuver (RM) has been shown to improve oxygenation for post-cardiopulmonary bypass (CPB) patients; however, sustained inflation of the lung gives rise to hypotension. The primary goal of our study was to evaluate the safety and efficacy of our proposed RM, defined on the basis of dynamic lung compliance (Cdyn). METHODS: Twenty-eight patients undergoing elective cardiac surgery with CPB were assigned to two treatment groups: an individualized RM group, in which a pressure equal to 15 ml x real body weight/Cdyn + positive end-expiratory pressure (PEEP) cmH2O was applied for 15 s; and a control RM group, in which a pressure of 20 cmH2O was applied for 25 s. Arterial blood pressure, cardiac output, pulmonary artery pressure, and heart rate (HR) were monitored. Tidal volume (V(T)), and airway pressure were continuously obtained from an expiratory flow meter and pressure monitor. Blood samples were obtained and analyzed with a blood gas analyzer. RESULTS: The changes in HR, mean arterial pressure, mean pulmonary artery pressure, and cardiac index at the end of the RM were not significantly different between the two groups. The mean airway pressure of sustained inflation was 28.3 +/- 1.3 cmH2O in the individualized RM group. The individualized RM significantly improved the Cdyn and partial pressure arterial oxygen/inspiratory fraction of oxygen (P/F) ratio compared with values in the control RM group (P = 0.026 and P = 0.012, respectively). CONCLUSION: The present study indicates that the individualized RM resulted in minimum changes of hemodynamics and brought about improvement in oxygenation and lung compliance.

Comparison of tracheal diameter measured by chest x-ray and by computed tomography.

Assessments of tracheal diameter (TD) are important to select proper endotracheal tubes. Previous studies have used X-ray and physical indices to estimate tracheal diameter but these may not reflect the actual TD. We compared TD measured by X-ray (TD-XP) and by computer tomography (TD-CT) in 200 patients. Also, we analyzed correlation of TD-CT with physical indices such as age, height, weight, and BMI. TD-XP and TD-CT were significantly correlated (male: n = 55, P = .0146; female: n = 91, P = .001). TD-XP was 0.4 mm wider in male and 1.0 mm wider in female than TD-CT. However, correlation coefficients of TD-XP and TD-CT are very weak (male: r = 0.36; female: r = 0.653). TD-CT did not correlate with age, height, weight, or BMI. Our findings suggest that correlations of TD-XP and TD are statistically significant but not clinically significant. Physical indices are not useful to estimate TD.

Effects of magnesium sulfate on neuromuscular function and spontaneous breathing during sevoflurane and spinal anesthesia.

The purpose of the present study was to determine the effects of magnesium sulfate (MgSO(4)) on the neuromuscular function and spontaneous breathing of patients under sevoflurane and spinal anesthesia. Twenty-two patients with a history of arrhythmia undergoing elective knee surgery were randomly assigned to two groups: group M (n = 11), administered with MgSO(4) 40 mg.kg(-1), and group S (n = 11), administered with saline. A combination of spinal anesthesia with 2% sevoflurane inhalation was applied to all patients under spontaneous breathing. Tidal volume (VT: ), respiratory rate (RR) and end-tidal carbon dioxide (ET(CO) (2)) were measured before the MgSO(4) or saline injection and measurements were repeated at 5, 15, 30, and 45 min after the injection. Neuromuscular function was continuously monitored with an acceleromyograph to record the acceleration of the adductor pollicis by stimulating the ulnar nerve at a frequency of 0.1 Hz. The VT: , RR, and ET(CO) (2) showed little change in either group, and there was no significant difference between, the groups. The single-twitch response showed significant differences between the two groups (P = 0.0006). The present study indicated that the MgSO(4) had a minimal effect on spontaneous breathing in patients undergoing sevoflurane and spinal anaesthesia, but that it attenuated the safety margin of neuromuscular function.

Platelet dysfunction during cardiopulmonary bypass assessed by a novel whole-blood aggregometer.

OBJECTIVE: The purpose of this study was to assess perioperative platelet function with 2 types of monitors (a whole-blood aggregometer [WBA analyzer; Mebanix, Tokyo, Japan]) and the Sonoclot monitor [Sienco, Wheat Ridge, CO]) in patients undergoing hypothermic cardiopulmonary bypass (CPB). DESIGN: Prospective, observational study. SETTING: Single-center study at a university hospital. PARTICIPANTS: Twenty-six patients who underwent coronary artery bypass grafting or valve replacement under hypothermic CPB without platelet transfusion or fresh frozen plasma administration. INTERVENTIONS: Blood sampling was performed at the following time periods: after anesthetic induction, after CPB, and on the first postoperative day. These samples were assessed with the WBA analyzer and the Sonoclot. MEASUREMENTS AND MAIN RESULTS: Significant attenuation of adenosine diphosphate-induced platelet aggregation was detected shortly after CPB by 2 WBA analyzer-derived parameters: a decrease in the filtration pressure rate and an increase in the platelet aggregatory threshold index. Platelet aggregation returned to the preoperative level on the next day. There was no correlation between the amount of postoperative mediastinal drainage and defects in platelet aggregation. On the other hand, time to peak obtained by the Sonoclot did not show any significant changes. CONCLUSIONS: Whole-blood aggregation measured with the WBA analyzer detected transient platelet dysfunction shortly after CPB, whereas the Sonoclot was less sensitive to this change.

Infusion of the beta-adrenergic blocker esmolol attenuates myocardial dysfunction in septic rats.

OBJECTIVE: Since beta-blocker therapy is known to be effective in patients with an injured heart, such as infarction, we designed the present study to examine the protective effects of infusion of the beta1-selective blocker esmolol on myocardial function in peritonitis-induced septic rats using an isolated working heart preparation. DESIGN: Randomized animal study. SETTING: University research laboratory. SUBJECTS: Thirty-one rats treated with cecal ligation and perforation to evoke peritonitis. INTERVENTIONS: After cecal ligation and perforation, rats were randomly allocated to the control group (normal saline 2 mL/hr, n = 11), low-dose esmolol group (10 mg/kg/hr, n = 10), or high-dose esmolol group (20 mg/kg/hr, n = 10). After obtaining blood samples for measurement of arterial lactate and tumor necrosis factor-alpha at 24 hrs, we assessed cardiac output, myocardial oxygen consumption, and cardiac efficiency (cardiac output x peak systolic pressure/myocardial oxygen consumption) at various preloads in an isolated perfused heart preparation. MEASUREMENTS AND MAIN RESULTS: Esmolol infusion did not cause an elevation of arterial lactate levels but reduced tumor necrosis factor-alpha concentrations vs. the control group (p < .05). Both cardiac output and cardiac efficiency in the esmolol-treated rats were significantly higher throughout the study periods vs. the control group (p < .05). CONCLUSIONS: Esmolol infusion in sepsis improved oxygen utilization of myocardium and preserved myocardial function.

Epidural analgesia prevents endotoxin-induced gut mucosal injury in rabbits.

In the present study, we evaluated the effect of epidural analgesia on the alterations of gut barrier function elicited by endotoxin in rabbits. After the placement of an epidural catheter, 28 male rabbits were randomized into either 0.5% lidocaine (group E) or saline (group C) group. The solutions (0.4 mL/kg) were epidurally injected, followed by continuous infusion (0.1 mL . kg(-1) . h(-1)) throughout the study period. Under a continuous infusion of lipopolysaccharide (15 microg . kg(-1) . h(-1)), mean arterial blood pressure, intramucosal pH, and plasma thrombomodulin concentrations were measured. At 4 h, mean arterial blood pressure was lower (P < 0.05), intramucosal pH was higher (P < 0.01), and the progression of hemodilution more profound (P < 0.05) in group E versus group C, whereas plasma thrombomodulin levels were increased to a similar extent between the groups. With less wet-to-dry weight ratio of ileum, histopathological injury scores of gut mucosa were significantly less in group E versus group C (P < 0.01). In a separate series of experiments (n = 10 each group), mucosal permeability in group E was significantly less compared with group C (P < 0.05). Collectively, these studies showed that despite a significant decrease of perfusion pressure and arterial oxygen content, epidural analgesia minimized endotoxin-induced functional and structural injury of gut mucosa possibly through endothelium-independent mechanisms.

Olprinone, a phosphodiesterase III inhibitor, reduces gut mucosal injury and portal endotoxin level during acute hypoxia in rabbits.

BACKGROUND: Preservation of gut integrity has become a therapeutic goal to obviate bacterial translocation in the critically ill. The authors examined whether olprinone, a phosphodiesterase III inhibitor, protected functional and structural integrity of gut mucosa against acute progressive hypoxia. METHODS: Thirty-two animals were randomly allocated to a control group (n = 12), a low-dose group (0.2 microg x kg-1 x min-1 olprinone; n = 10), or a high-dose group (0.6 microg x kg-1 x min-1 olprinone; n = 10) after preparatory surgery. Ascending aortic and portal blood flow, intramural pH of the ileum, and portal endotoxin levels were measured at normoxia and through three stages of progressive hypoxia (fraction of inspired oxygen = 0.17, 0.13, and 0.10). RESULTS: At normoxia, ascending aortic flow in the high-dose group was approximately 20% higher than in the control and low-dose groups. During progressive hypoxia, both ascending aortic and portal flow in the control group were depressed, whereas olprinone infusion attenuated such alterations and redistributed blood to the splanchnic area in a dose-dependent manner. On the contrary, the reduction of intramural pH of the ileum and the elevation of portal endotoxin levels observed in the control group were significantly minimized in both the low- and high-dose groups to a similar extent during acute hypoxia. Histopathologic alterations of gut mucosa observed in the control group were minimized by olprinone infusion dose-independently, accompanied by reduction of mortality rate of the animals. CONCLUSIONS: Olprinone slows progression of intestinal mucosal acidosis and gut barrier dysfunction, concurrently with preservation of microscopic structures, through both flow-dependent and -independent mechanisms under acute hypoxia. Such properties of olprinone may serve to protect the host under insult.

Massive hepatic infarction in preeclampsia: successful treatment with continuous hemodiafiltration and corticosteroid therapy.

Massive hepatic infarction associated with pregnancy is extremely rare, but is potentially fatal. A 35-year-old primigravida with mild preeclampsia developed acute right upper quadrant pain and marked elevation of liver enzymes at 26 weeks' gestation. After emergent cesarean section, her condition was complicated by oliguric renal failure and pulmonary edema with further deterioration of hepatic function (aspartate transaminase 4339 IU/L; alanine transaminase 3489 IU/L; lactate dehydrogenase 10780 IU/L). The contrast-enhanced computed tomography revealed non-enhancing low attenuation throughout the right lobe of liver, compatible with infarction. Continuous hemodiafiltration was initiated as renal support on postpartum day one. However, excessive fluid accumulation persisted, and she developed severe edema formation in both lung and systemic body surface. To ameliorate microvascular endothelial injury, corticosteroid therapy was begun on postpartum day five. Following treatment initiation, her renal and hepatic function showed steady improvement, accompanied by drastic resolution of edema formation. She was discharged five weeks postpartum with no additional treatment, and is without sequelae six months later. Massive hepatic infarction should be considered in preeclamptic patients who present acute abdominal pain and severe hepatic dysfunction, and continuous hemodiafiltration with corticosteroid therapy may improve the maternal outcome.