Factors Affecting the Absorption of Midazolam to the Extracorporeal Membrane Oxygenation Circuit.

Sedatives are administered during extracorporeal membrane oxygenation (ECMO) therapy to ensure patient safety, reduce the metabolic rate and correct the oxygen supply-demand balance. However, the concentrations of sedatives can be decreased due to absorption into the circuit. This study examined factors affecting the absorption of a commonly used sedative, midazolam (MDZ). Using multiple ex vivo simulation models, three factors that may influence MDZ levels in the ECMO circuit were examined: polyvinyl chloride (PVC) tubing in the circuit, use of a membrane oxygenator in the circuit, and heparin coating of the circuit. We also assessed changes in drug concentration when MDZ was re-injected in a circuit. The MDZ level decreased to approximately 60% of the initial concentration in simulated circuits within the first 30 minutes. The strongest factor in this phenomenon was contact with the PVC tubing. Membrane oxygenator use tended to increase MDZ loss, whereas heparin circuit coating had no influence on MDZ absorption. Similar results were obtained when a second dose of MDZ was injected to the second-use circuits.

Citrobacter braakii bacteremia-induced septic shock after colonoscopy preparation with polyethylene glycol in a critically ill patient: a case report.

BACKGROUND: Polyethylene glycol (PEG) is widely used for bowel cleaning in preparation for colonoscopy because of its safety. Septic shock after PEG preparation is an extremely rare complication. Herein, we describe a case of septic shock that occurred immediately after colonoscopy preparation with PEG. CASE PRESENTATION: A 75-year-old Japanese male who had previously developed diabetes after total pancreatectomy received PEG in preparation for colonoscopy. He had been admitted to the emergency intensive care unit 4 days earlier due to hematochezia presenting with shock. He ingested PEG to prepare for a colonoscopy examination, which was performed to identify the source of his bleeding over a 5-h period, but suddenly exhibited septic shock and markedly elevated procalcitonin levels. A blood culture subsequently revealed Citrobacter braakii. Immediate resuscitation and intensive care with appropriate antibiotics improved his condition. CONCLUSIONS: Clinicians should be aware of the possibility of deteriorating conditions after bowel preparation with PEG among severely ill patients with recent episodes of hemorrhagic shock.

Incidence and characteristics of medical emergencies related to dental treatment: a retrospective single-center study.

AIM: Although uncommon, medical emergencies arise in general dental practice. Inadequate data on their severity and frequency makes targeting medical education for general dental practitioners difficult. This also makes planning for unexpected events challenging for practitioners and makes collaborating with emergency physicians burdensome. We aimed to clarify the incidence and characteristics of a dental outpatient department's medical emergencies. METHODS: This single-center, retrospective, observational study was undertaken with patients who visited the dental outpatient department of Okayama University Hospital during the 8-year period. The primary outcome of the study was to identify the incidence and characteristics of medical emergencies in the dental outpatient department. Then we examined the timing of medical emergencies, administered medications, and final disposition (home/admission). RESULTS: During the period, 1,146,929 patients were enrolled. Forty-two patients (0.0037%) were consulted as medical emergencies. More than 60% of the incidents were vasovagal syncope, and dehydration and hypoglycemia were the second most prevalent at 9.5%. The most common types of dental treatments were tooth extraction (45.2%), followed by general dental treatment (28.6%), and other dental surgery such as implant placement (14.3%). Types of medical emergencies occurred equally before, during, and after dental treatment. Antihypertensive agents, sedatives, or glucose were used. For patients with emergencies, 90.5% recovered during the day and returned home, and 9.5% were hospitalized. CONCLUSION: The incidence of medical emergencies was low in our dental outpatient department. Knowledge of basic management principles, regular education for emergency care, and practicing first aid skills are mandatory for safe patient management.

Burning Mouth Syndrome Induced by Angiotensin-Converting Enzyme Inhibitors.

Burning mouth syndrome (BMS) is characterized as the sensation of burning in the tongue or any other area of the oral mucosa without a medical or dental cause. BMS's pathophysiology is poorly understood and may be caused by its association with various factors, particularly with antihypertensive or psychotropic medicines. Although BMS is a relatively common intraoral disorder in the dental field, emergency physicians rarely recognize it. We report a 53-year-old Japanese woman who presented to our ED with a three-week history of a strange taste and burning tongue. The patient had poor control of hypertension, captopril, an angiotensin-converting enzyme (ACE) inhibitor, was added three weeks before presentation. We discontinued her ACE inhibitor and changed her medication to a beta-blocker. After two weeks, her symptoms improved. Emergency physicians must be aware that ACE inhibitors play some roles in the pathogenesis of BMS. The correct diagnosis of the condition depends on recognizing the disease and improving the quality of life.

Relative contribution of direct and indirect allorecognition in developing tolerance after liver transplantation.

The interaction of donor passenger leukocytes and host leukocytes in recipient secondary lymphoid tissues during the early posttransplantation period is crucial in directing host immune reactions toward allograft rejection or acceptance. Responsible T cell clones could be activated through the direct and indirect pathways of allorecognition. We examined the role of the indirect pathway in liver transplantation (LT) tolerance by depleting host antigen-presenting cells (APC) with phagocytic activity [e.g., cluster domain (CD)68+/CD163+ macrophages, CD11c+ dendritic cells (DC)] using liposome-encapsulating clodronate (LP-CL). After Lewis rat cell or liver graft transplantation, Brown Norway (BN) rat recipients pretreated with LP-CL showed a significantly reduced type 1 helper T cell cytokine up-regulation than control-LP-treated recipients. In the LT model, LP-CL treatment and host APC depletion abrogated hepatic tolerance; Lewis liver grafts in LP-CL-treated-BN recipients developed mild allograft rejection, failed to maintain donor major histocompatibility complex (MHC) class II+ leukocytes, and developed chronic rejection in challenged donor heart allografts, while control-LP-treated BN recipients maintained tolerance status and donor MHC class II+ hepatic leukocytes. Furthermore, in the BN to Lewis LT model, LP-CL recipient treatment abrogated spontaneous hepatic allograft acceptance, and graft survival rate was reduced to 43% from 100% in the control-LP group. In conclusion, the study suggests that host cells with phagocytic activity could play significant roles in developing LT tolerance.

Iatrogenic subcutaneous emphysema and pneumomediastinum following a high-speed air drill dental treatment procedure.

Case: A patient was transported to our hospital with swelling in his right face and neck after restorative dental treatment. Subcutaneous emphysema and pneumomediastinum were discovered using computed tomography scans. Outcome: The patient had no severe symptoms. We prescribed prophylactic antibiotics and he recovered uneventfully. Conclusions: Clinicians must keep this pathology in mind because prompt diagnosis and treatment contribute to early improvement. Otherwise, patients may face life-threatening complications.

A polyurethane vascular access graft and a hybrid polytetrafluoroethylene graft as an arteriovenous fistula for hemodialysis: comparison with an expanded polytetrafluoroethylene graft.

AIM: We evaluated a polyurethane vascular access graft (TVAG), a hybrid polytetrafluoroethylene graft (hPTFEG), and an expanded polytetrafluoroethylene graft (ePTFEG) for postoperative complications and graft patency in their use as prosthetic devices of vascular access for hemodialysis. METHODS: Between August 1993 and October 2001, we treated 200 patients in whom A-V fistulas were placed by the same surgeon. These were divided into the following four groups according to the type of blood access: 27 cases of ePTFEG, 23 cases of TVAG, 22 cases of hPTFEG, and 128 cases of an autogenous A-V fistula. We calculated the cumulative patency rates by the Kaplan-Meier method, including primary (problem-free) and secondary (revised or functional) patency rates. RESULTS: The hPTFEG group experienced few thromboses. The absence of perigraft edema in the TVAG group permitted the early use of the TVAG within a few postoperative days for hemodialysis. Among the three graft groups, the primary patency was the best in the hPTFEG group (94.7% at 1 year and 86.1% at 2 years), with a significant difference versus the ePTFEG group. In regard to secondary patency, hPTFEG had an excellent patency of 100% at 1 year and 90.9% at 2 years, and TVAG had a comparable patency with that of ePTFEG. CONCLUSION: The hPTFEG was considered superior to ePTFEG in terms of being complication-free and had the excellent 2 year secondary patency of 90.9%. TVAG, with a patency equal to that of ePTFEG, could be used immediately after implantation due to the absence of limb edema.