A Case Report of a Diaphragmatic Defect Developing Into a Late-Presenting Congenital Diaphragmatic Hernia With Severe Respiratory Failure.

Diaphragmatic hernia is a congenital malformation, often discovered in the neonatal period, and its occurrence in adults is very rare. This patient, who was completely asymptomatic until the age of 62, had developed an intestinal obstruction and went into respiratory failure after surgery for an external auditory canal carcinoma. He was subsequently diagnosed with a late-presenting congenital diaphragmatic hernia (CDH), thus requiring surgical treatment. Anesthesiologists and critical care physicians should keep in mind the possibility of CDH as well as diaphragmatic relaxation when an unexplained elevation of the diaphragm is observed perioperatively.

The short-term efficacy of high flow nasal oxygen therapy on cardiovascular surgical patients: a randomized crossover trial.

BACKGROUND: Oxygen therapy after extubation in the intensive care unit (ICU) is essential in order to maintain adequate oxygenation, especially in patients who have undertaken cardiovascular surgery. A Venturi mask (VM) has been routinely used as an oxygen therapy in the ICU. Recently, however, the high flow nasal cannula (HFNC) has become available, and this device can deliver up to 60 L/min of humidified oxygen. The aim of this study is to evaluate the short-term efficacy between HFNC and VM in cardiovascular surgical patients. METHODS: Forty patients who underwent cardiovascular surgery were randomized to either protocol A (HFNC followed by VM) or protocol B (VM followed by HFNC). After 60-minutes of use with either device, arterial blood gas analysis was performed, and the PaO2/FiO2 ratio (PFR) was calculated. Simultaneously, physiological data (respiratory rate, heart rate, mean arterial pressure, continuous cardiac index, and mixed venous oxygen saturation) were recorded. During this procedure, FiO2 and gas flow were maintained at a fixed rate. These variables were compared by using the paired t-test, and a p value < 0.05 was considered significant. All data were expressed as mean (standard deviation). RESULTS: Thirty-five patients (17 from protocol A and 18 from protocol B) were enrolled, and 5 patients were excluded from analysis in accordance with the exit criteria. PaO2 was significantly higher in the HFNC group than in the VM group [101.7 (25.9) vs. 91.8 (23.0), mean difference 9.87 (18.5), 95% confidence interval 3.5 to 16.2, p = 0.003]. Moreover, PFR was significantly higher in the HFNC group than in the VM group [265.9 (81.4) vs. 238.7 (68.5), p = 0.002]. Moreover, PaCO2 was significantly lower in the HFNC group than in the VM group [33.8 (3.5) vs. 34.7 (2.9), p = 0.033]. The respiratory rate was significantly lower in the HFNC group than in the VM group [18 (4) vs. 21 (4), p = 0.006], and no significant differences were seen in any of the other parameters. CONCLUSIONS: Compared to VM, HFNC ameliorated oxygenation function and decreased patients' effort in breathing. The hemodynamic state did not differ between HFNC and VM. Therefore, HFNC can be used safely in cardiovascular surgical patients. TRIAL REGISTRATION: This trial was registered with the UMIN Clinical Trials Registry (ID UMIN000016572).

PaO2 / FiO2 ratio responsiveness to prone positioning in intubated patients with severe COVID-19: a retrospective observational study.

Aim: Prone positioning of coronavirus disease 2019 (COVID-19) patients could improve oxygenation. However, clinical data on prone positioning of intubated COVID-19 patients are limited. We investigated trends of PaO2 / FiO2 ratio values in patients during prone positioning to identify a predictive factor for early detection of patients requiring advanced therapeutic intervention such as extracorporeal membrane oxygenation (ECMO). Methods: This retrospective, observational cohort study was undertaken between April 2020 and May 2021 in a tertiary referral hospital for COVID-19 in Osaka, Japan. We included intubated adult COVID-19 patients treated with prone positioning within the first 72 h of admission to the intensive care unit and followed them until hospital discharge or death. Primary outcomes were in-hospital mortality and escalation of care to ECMO. We used unsupervised k-means clustering modeling to categorize COVID-19 patients by PaO2 / FiO2 ratio responsiveness to prone positioning. Results: The final study cohort comprised 54 of 155 consecutive severe COVID-19 patients. Three clusters were generated according to trends in PaO2 / FiO2 ratios during prone positioning (cluster A, n = 16; cluster B, n = 24; cluster C, n = 14). Baseline characteristics of all clusters were almost similar. Cluster A (no increase in PaO2 / FiO2 ratio during prone positioning) had a significantly higher proportion of patients placed on ECMO or who died (6/16, 37.5%). Numbers of patients with ECMO and with in-hospital death were significantly different between the three groups (p = 0.017). Conclusion: In Japanese patients intubated due to COVID-19, clinicians should consider earlier escalation of treatment, such as facility transfer or ECMO, if the PaO2 / FiO2 ratio does not increase during initial prone positioning.

Young Healthy Patient With Severe COVID-19 and Fulminant Community-Acquired Pseudomonas aeruginosa Pneumonia: A Case Report.

Community-acquired pneumonia (CAP) caused by Pseudomonas aeruginosa in healthy adults can rapidly lead to severe outcomes. We treated a case of P. aeruginosa-induced CAP and concurrent severe coronavirus disease (COVID-19) in a healthy 39-year-old man without other serious risk factors for severe illness except smoking. Immediately after admission, the patient developed sepsis and received intensive broad-spectrum antibacterial therapy with meropenem and vancomycin, veno-arterial extracorporeal membrane oxygenation (VAECMO), and catecholamine supplementation. Despite receiving multidisciplinary treatment, the patient died within 24 hours. P. aeruginosa with normal antimicrobial susceptibility was identified in blood and sputum cultures of samples taken at admission. Gram staining of the bacteria detected in blood cultures was suspicious for non-glucose-fermenting Gram-negative rods, including P. aeruginosa, and the antimicrobial regimen that was initiated following admission was considered effective. The patient was a plumber and a smoker, which are risk factors for P. aeruginosa-induced CAP, and the clinical course matched those in previous reports of P. aeruginosa-induced CAP, including necrotizing pneumonia with cavities and rapid progression of sepsis. Although COVID-19 can be the sole cause of septic shock, the combination of P. aeruginosa bacteremia and COVID-19 was possibly the cause of septic shock in this case. Even during an infectious disease pandemic, reviewing the patient's occupational history and comorbidities and performing blood and sputum culture tests, including Gram staining, are important for the provision of appropriate treatment.

Urinary neutrophil gelatinase-associated lipocalin was a predictor from the day after intensive care unit entry, but not on the day of intensive care unit entry.

BACKGROUND AND AIMS: Sepsis is the main cause of death from infection. This study aimed to determine whether neutrophil gelatinase-associated lipocalin (NGAL) values better predict mortality in septic patients when combined with inflammation-based prognostic scores. MATERIAL AND METHODS: Forty-four adult patients diagnosed according to the Sepsis-3 definition and who were admitted to the ICU were prospectively examined from June 2018 to November 2018. Urine samples were collected from each patient with a urethral balloon bag to measure NGAL after ICU entry at the following time points: immediately after and 2, 3, and 4 days after ICU entry. The Glasgow Prognostic Score, the neutrophil to lymphocyte ratio (NLR), the platelet to lymphocyte ratio, the Prognostic Nutritional Index, the Prognostic Index (PI), the Sequential Organ Failure Assessment (SOFA), and quick SOFA were examined immediately after ICU entry. Predictors of mortality were assessed by receiver operating characteristics curve (ROC) analysis, log-rank test, and multivariate logistic regression analysis. RESULTS: NGAL on day 4 (AUC: 0.94) and ΔNGAL from day 4 to day 1 (AUC: 0.9) for 28-day mortality; NGAL on day 4 (AUC: 0.94) and inflammation-NGAL score (iNS) NGAL-PI (AUC: 0.69) for 60-day mortality; ΔNGAL from day 3 to day 1 (AUC: 0.82) for 90-day mortality; and iNS NGAL-NLR (AUC: 0.71) and iNS NGAL-PI (AUC: 0.68) for in-hospital mortality were found to be predictors of mortality by ROC curve analysis. NLR (p = 0.02) for 28-day mortality; NGAL on day 2 (p = 0.031), ΔNGAL from day 2 to day 1 (p = 0.013), and NLR (p < 0.0001) for 60-day mortality; NGAL on day 2 (p = 0.017), ΔNGAL from day 2 to day 1 (p = 0.014), and NLR (p = 0.033) for 90-day mortality; and NGAL on day 2 (p = 0.007) for in-hospital mortality were found to be predictors of mortality by log-rank test. iNS NGAL-NLR (OR, 0.024; p = 0.019) for 60-day mortality and NGAL from day 3 to day 1 (OR, 1.005; p = 0.013) for 90-day mortality were found to be predictors of mortality by multivariate logistic regression analysis. CONCLUSIONS: NGAL and ΔNGAL were predictors of mortality in sepsis patients on day 2 after ICU entry and thereafter, but not on day 1.

Urinary neutrophil gelatinase-associated lipocalin values alone and combined with Prognostic Index predict septic AKI, DIC, and shock: a pilot study.

OBJECTIVE: Sepsis is a syndrome involving life-threatening organ dysfunction. The present study aimed to determine whether septic AKI, ARDS, DIC, and shock can be predicted more readily by combining uNGAL values and inflammation-based prognostic scores, over the use of uNGAL values alone. RESULTS: ROC curve analyses yielded the following cut-off values: AKI: 438.5 (ng/ml) for uNGAL at Day 1 (AUC, 0.8), 476.9 (ng/ml) for uNGAL at Day 2 (AUC, 0.86), 123.8 (ng/ml) for uNGAL at Day 3 (AUC, 0.81), 133.6 (ng/ml) for uNGAL at Day 4 (AUC, 0.78), 1.0 for iNS NGAL-NLR (AUC, 0.75), 2.0 for iNS NGAL-PI (AUC, 0.77), DIC; 648.5 (ng/ml) for uNGAL at Day 1 (AUC, 0.77); shock; 123.8 (ng/ml) for uNGAL at Day 3 (AUC, 0.71) and 9 for SOFA (AUC, 0.71). Multivariate logistic regression analyses revealed iNS NGAL-PI to be a significant independent predictor of AKI (OR, 20.62; 95% CI, 1.03-412.3; p = 0.048).

Exploring the use of single-port surgery in the conservative management of hepatic portal vein gas: A case report.

RATIONALE: Hepatic portal vein gas (HPVG) is known as a sign of a lethal condition resulting from bowel necrosis. Recently, the detection rate of non-life-threatening cases of HPVG has increased due to the technological development of imaging, i.e., computed tomography (CT). However, it is difficult to determine accurately whether surgical treatment is necessary because of its lethal potential. PATIENT CONCERNS: A 74-year-old woman suddenly complained about lower abdominal pain and vomiting after an operation for cervical spondylosis myelopathy. Her vital signs were slightly unstable and she was perspiring and exhibited pallor. Muscular defense was not clear, though her abdomen was tender and slightly distended. DIAGNOSIS: CT results showed massive HPVG. However, laboratory investigation did not clearly indicate bowel necrosis. Also, a contrast-CT scan was not performed due to her chronic renal dysfunction and asthma. INTERVENTION: Exploration was performed by single-port surgery (SPS) instead of exploratory laparotomy. OUTCOME: This approach showed no ischemic bowel and so conservative therapies were undertaken with confidence. The HPVG disappeared 2 days later, and she recover completely from the illness. LESSONS: HPVG requires immediate and reliable decision for management. However, unnecessary exploratory laparotomy should be avoided. Hence, a novel strategy should be considered in light of innovative surgical procedures. Our experience suggested that SPS was useful as an exploratory tool for the management of HPVG.

Bacillus cereus pneumonia in an immunocompetent patient: a case report.

BACKGROUND: Bacillus cereus (B. cereus) rarely causes lower respiratory tract infections, although most reported cases of B. cereus pneumonia are fatal despite intensive antibiotic therapy. We present a case of B. cereus pneumonia in an immunocompetent patient. CASE PRESENTATION: An 81-year-old woman was transferred from a district general hospital to our hospital for treatment of congestive heart failure. The patient presented with a nonproductive cough, dyspnea, edema in both lower extremities, orthopnea, fever, and occult blood in the stool. A chest radiograph indicated bilateral pleural effusion and pulmonary congestion. After diuretic therapy and chest drainage, bilateral pleural effusion and pulmonary congestion improved. On day 2, she experienced severe respiratory distress. B. cereus was isolated from two blood sample cultures. On day 4, her condition had progressed to severe respiratory distress (PaO2/FiO2 ratio = 108). A chest radiograph and computed tomography indicated extensive bilateral infiltrates. She was transferred to the intensive care unit and was intubated. B. cereus was also isolated from five blood sample cultures at that time. After isolating B. cereus, we switched antibiotics to a combination of imipenem and levofloxacin, which were effective. She had no history of immunodeficiency, surgery, ill close contacts, risk factors for HIV or tuberculosis, recent central venous catheter insertion, or anthrax vaccination. She improved and was discharged from the intensive care unit after several days. CONCLUSION: This is a rare case of B. cereus pneumonia in an immunocompetent patient, who subsequently recovered. Bacillus should be considered as a potential pathogen when immunocompetent patients develop severe pneumonia.

Anti-NMDA receptor encephalitis presenting as an acute psychotic episode misdiagnosed as dissociative disorder: a case report.

BACKGROUND: In 2005, "anti-N-methyl-d-aspartate (NMDA) receptor encephalitis," a syndrome with prominent psychiatric symptoms, memory loss, decrease in level of consciousness, and central hypoventilation, was described in young women with ovarian teratomas and antibodies against an antigen highly expressed in the hippocampus. This report highlights the growing need for increased awareness among psychiatrists and other relevant medical professionals about this under-diagnosed disorder, which should be considered in differential diagnoses. CASE PRESENTATION: A 19-year-old female with no psychiatric history presented to a district general hospital with acute psychosis, emotional lability, memory deficit, fluctuating behavioral changes such as wandering and babbling, and seizure. She was admitted to the hospital with a provisional diagnosis of dissociative disorder. Soon after admission, she developed aspiration pneumonia and was intubated for mechanical ventilation. She was transferred to our hospital for further assessment and admitted to the intensive care unit for ventilation. Laboratory test results were unremarkable, but her EEG showed non-specific slowing with no epileptiform activity, and brain computed tomography (CT) and MRI also showed no remarkable findings. Cerebrospinal fluid (CSF) analysis showed an elevated white blood cell count (15 cells/hpf; 70 % lymphocytes), and blood serum and CSF samples tested positive for NMDA receptor antibodies. Abdominal contrast-enhanced CT revealed an ovarian teratoma, which was subsequently removed laparoscopically. Postoperative immunotherapy (steroids, intravenous immunoglobulin, and plasmapheresis) led to gradual improvement. On day 25 of hospitalization, neuropsychological assessment demonstrated that overall, she had returned to her premorbid level of functioning. Her condition substantially improved over several months of cognitive rehabilitation, and she was eventually discharged on day 75. CONCLUSIONS: Anti-NMDA receptor encephalitis, a form of autoimmune encephalitis, is commonly associated with tumors and often misdiagnosed. Diagnosis can be confirmed by detecting NMDA receptor antibodies in the patient's serum or CSF. Management can be achieved with immunosuppressive therapy and tumor resection.

[Development of Takotsubo Cardiomyopathy during Recovery from General Anesthesia: A Case Report].

Takotsubo cardiomyopathy is a cardiac syndrome characterized by transient left ventricular dysfunction. A 61-year-old woman underwent laparoscopic cholecystectomy under general anesthesia. During recovery from general anesthesia, several arrhythmias occurred without cardiac collapse following desflurane discontinuation and sugammadex sodium administration. She had a chest pain after extubation, with ST segment elevation in leads aV(L) and V2-4. Emergency left ventricular angiogram revealed no significant coronary stenosis, and excessive contraction of the base and severe hypokinesis of the apex suggested Takotsubo cardiomyopathy. Sympathetic hyperactivity during acute recovery from anesthesia with desflurane discontinuation and muscle relaxant reversal with sugammadex sodium was considered the likely cause of Takotsubo cardiomyopathy.

Use of central venous saturation monitoring in a patient with pediatric cardiac beriberi.

The patient was a 1-year-and-4-mo-old boy. He had drunk about 1 L of an isotonic drink for infants daily since about 10 mo after birth. He was examined by a local doctor due to anorexia and vomiting, found to have cardiomegaly, and transported to our hospital with suspected myocarditis. After admission, the patient showed polypnea, a decreased level of consciousness, and marked metabolic acidosis and lapsed into circulatory insufficiency, requiring catecholamine administration, endotracheal intubation, and extracorporeal membrane oxygenation. Initially, low-output heart failure due to acute myocarditis was suspected, but the central venous oxygen saturation was high, at 82%. Considering high-output heart failure to be more likely, we evaluated its cause and noted, by urinary organic acid analysis, increases in lactate, pyruvate, 3-OH-butyrate, acetoacetate, metabolic products of branched-chain amino acids, 2-ketoglutarate, 2-OH-glutarate, 2-keto-adipate, and 2-OH-adipate. Since the vitamin B1 level was reduced to 12 ng/mL (normally 20-50 ng/mL), a diagnosis of cardiac beriberi due to vitamin B1 deficiency was made. When unexplained heart failure is observed in children, cardiac beriberi must be excluded as a differential diagnosis of myocarditis and cardiomyopathy. The measurement of the central venous oxygen saturation may be useful for the diagnosis.

Post-operative dexmedetomidine-based sedation after uneventful intracranial surgery for unruptured cerebral aneurysm: comparison with propofol-based sedation.

BACKGROUND: Clinical applications of dexmedetomidine (DEX) for neurosurgical procedures have not been adequately investigated. This study aimed to test the use of DEX infusion, alone or as an adjunct to propofol infusion, as compared to propofol infusion in patients with an unruptured cerebral aneurysm after uneventful intracranial procedures. METHODS: In this retrospective observational study from a single institute, of 184 patients who underwent uneventful intracranial procedures for an unruptured cerebral aneurysm between January 2003 and March 2007, we reviewed 50 managed with DEX-based sedation (DEX alone or as an adjunct to propofol infusion) between April 2005 and March 2007, and 50 managed with propofol-based sedation (propofol alone) between January 2003 and April 2005. With DEX-based sedation, both intubated and extubated patients received DEX infusion at an initial dose of 0.4 µg/kg/h, followed by a maintenance dose of 0.2-0.7 µg/kg/h. Propofol was used in both groups at a dose range of 0.5-5.0 mg/kg/h. Hemodynamic variables, including heart rate (HR) and blood pressure (BP), and adverse events were recorded and compared between the groups. RESULTS: HR during sedation and systolic BP at 2 h after beginning sedation were significantly lower in the DEX group. No serious adverse events were observed. In the DEX group, 66% were sedated in combination with propofol, of whom 94% were intubated. CONCLUSIONS: DEX could be used safely for both intubated and extubated patients following uneventful intracranial procedures for an unruptured cerebral aneurysm, though it significantly reduced HR. Our findings also indicate that it is preferable to add low-dose propofol to DEX for management of intubated patients.

Oral sildenafil for persistent pulmonary hypertension early after congenital cardiac surgery in children.

OBJECTIVE: Sildenafil is a strong pulmonary vasodilator that increases the intracellular cyclic guanosine monophosphate concentration through inhibition of phosphodiesterase-5. We assessed the benefit of oral sildenafil for persistent pulmonary hypertension early after congenital cardiac surgery in paediatric patients. METHODS: Sildenafil was administered at a starting dose of 0.5 mg kg(-1) following admission to the intensive care unit. With careful monitoring of haemodynamics, the dose was increased stepwise by 0.5 mg kg(-1) every 4-6 h up to a maximum of 2 mg kg(-1). After successful weaning from a ventilator and from other vasodilators, sildenafil was gradually discontinued over the next 5-7 days. RESULTS: A retrospective review of medical records showed an age distribution of <1 month (n=26), > or = 1-<6 months (n=36), > or = 6-<12 months (n=19), 1-3 years (n=8), 4-9 years (n=9) and >10 years (n=2) at the time of surgery. The surgeries were performed for ventricular septal defect closure (n=17), arterial switch (n=30), truncus arteriosus repair (n=10), complete atrioventricular septal defect repair (n=12), total anomalous venous drainage repair (n=9), and other open-heart surgery (n=22). The aforementioned concomitant inhaled nitrous oxide treatment was performed in 66 patients. Pulmonary arterial pressure decreased in 28, was unchanged in five and elevated in one patient out of the total of 34 cases for which data from continuous pressure monitoring were available. Bosentan was added in three cases with persistent symptoms due to pulmonary hypertension despite sildenafil treatment. After sildenafil administration, modest oxygen desaturation occurred in seven cases, but no 'rebound' pulmonary hypertension occurred. There were no significant adverse events during sildenafil treatment. CONCLUSIONS: Our results suggest that oral sildenafil is a safe and effective alternate for persistent pulmonary hypertension following congenital heart surgery in children.