Anesthetic management of airway stent placement by rigid bronchoscopy with superior laryngeal nerve block while preserving spontaneous breathing: A case report.

Key Clinical Message: The combination of superior laryngeal nerve block can reduce the respiratory depression that occurs during management under total intravenous anesthesia. Abstract: Anesthetic management of endobronchial stent placement by rigid bronchoscopy requires the maintenance of spontaneous breathing while suppressing upper airway reflexes. The combination of superior laryngeal nerve block (SLNB) can reduce the respiratory depression that occurs during management under total intravenous anesthesia. The patient was diagnosed as having lung cancer with invasion into the right middle bronchus and stenosis of the right main bronchus on chest computed tomography, and emergency airway stent placement was performed. Sedation was initiated with propofol and dexmedetomidine, and ultrasound-guided SLNB was performed after local anesthetic spraying into the oral cavity and trachea. Bucking was minimally controlled during insertion of the rigid bronchoscope. The patient's intraoperative hemodynamics remained stable, and there were no hypoxic events. SLNB can provide the suppression of the upper airway reflex while minimizing effects on spontaneous breathing, and may be useful for achieving balanced anesthesia during rigid bronchoscopy.

Licochalcone E, a ß-Amyloid Aggregation Inhibitor, Regulates Microglial M1/M2 Polarization via Inhibition of CTL1-Mediated Choline Uptake.

Alzheimer's disease (AD) is thought to be a series of neuroinflammatory diseases caused by abnormal deposits of amyloid-ß (Aß) and tau protein in the brain as part of its etiology. We focused on Aß aggregation and M1 and M2 microglial polarity in microglia to search for novel therapeutic agents. It has been reported that the inhibition of choline uptake via choline transporter-like protein 1 (CTL1) in microglia preferentially induces M2 microglial polarity. However, the role of the choline transport system on the regulation of microglial M1/M2 polarity in AD is not fully understood. Licochalcones (Licos) A-E, flavonoids extracted from licorice, have been reported to have immunological anti-inflammatory effects, and Lico A inhibits Aß aggregation. In this study, we compared the efficacy of five Licos, from Lico A to E, at inhibiting Aß1-42 aggregation. Among the five Licos, Lico E was selected to investigate the relationship between the inhibition of choline uptake and microglial M1/M2 polarization using the immortalized mouse microglial cell line SIM-A9. We newly found that Lico E inhibited choline uptake and Aß1-42 aggregation in SIM-A9 cells in a concentration-dependent manner, suggesting that the inhibitory effect of Lico E on choline uptake is mediated by CTL1. The mRNA expression of tumor necrosis factor (TNF-α), a marker of M1 microglia, was increased by Aß1-42, and its effect was inhibited by choline deprivation and Lico E in a concentration-dependent manner. In contrast, the mRNA expression of arginase-1 (Arg-1), a marker of M2 microglia, was increased by IL-4, and its effect was enhanced by choline deprivation and Lico E. We found that Lico E has an inhibitory effect on Aß aggregation and promotes polarity from M1 to M2 microglia via inhibition of the CTL1 function in microglia. Thus, Lico E may become a leading compound for a novel treatment of AD.

Necrotizing fasciitis and septic shock due to streptococcal toxic shock syndrome in an elderly patient: A case report.

Streptococcal toxic shock syndrome (STSS) has a high mortality rate, and most patients die within a few days of onset. We report an elderly patient with STSS, necrotizing fasciitis and septic shock caused by group G streptococcus who was successfully treated with multidisciplinary therapy.

Successful Perioperative Management of Cochlear Implantation in a Patient With Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes (MELAS).

Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a type of mitochondrial disease that is characterized by stroke-like seizures. For these patients, serious, unexpected complications have occurred during and following anesthetic exposure. Provision of anesthesia is challenging, including the choice of anesthetic agents. We here report a case of general anesthesia management for a patient with MELAS. A 46-year-old woman was diagnosed with MELAS at the age of 40. She subsequently underwent cochlear implantation for hearing loss. Anesthesia was induced with midazolam and maintained with desflurane. In the present case, anesthesia was maintained with inhalation anesthetics to avoid the development of propofol infusion syndrome. Her intraoperative and postoperative courses were uneventful. The anesthesia management of patients with MELAS can be performed safely with carefully planned anesthesia and close monitoring at each step, including the postoperative period.

Esophageal Submucosal Giant Hematoma Detected After Mitral Repair Using Transesophageal Echocardiography.

Transesophageal echocardiography (TEE) is a necessary diagnostic tool for cardiac surgery, including for intraoperative evaluation of the morphology and function of each structure. On the other hand, many complications caused by insertion and manipulation of the TEE probe have been reported, such as gastrointestinal injuries and hematoma, as well as esophageal perforation. Here, we report a case in which a large submucosal esophageal hematoma was found on the fourth postoperative day after surgery using TEE for mitral regurgitation. The patient was an 81-year-old man who underwent mitral valve replacement for mitral regurgitation. On the fourth postoperative day, anorexia and blood-tinged sputum were observed. A computed tomography (CT) scan of the chest displayed a giant esophageal submucosal hematoma. When performing TEE, to avoid complications, it is important to handle the TEE probe with care and to avoid leaving the device at the same site for long periods of time.

Functional Expression of Choline Transporters in Microglia and Their Regulation of Microglial M1/M2 Polarization.

BACKGROUND: Microglia are key cells of the immune system in the central nervous system and are suggested to be deeply involved in the development of neurodegenerative diseases. It is well known that microglia have functional plasticity, with an inflammatory M1 phenotype and an anti-inflammatory M2 phenotype. Inhibition of choline transport in macrophages has been reported to suppress the secretion of inflammatory cytokines. However, the role of the choline transport system in regulating microglial M1/M2 polarization has not been fully elucidated to date. In this study, we investigated the mechanism of choline uptake in microglia, and its association with microglial M1/M2 polarization. METHODS: The immortalized mouse microglial cell line SIM-A9 was used for [3H]choline uptake and expression analysis of choline transporters. The association between the choline uptake system and the M1/M2 polarization of microglia was also analyzed. RESULTS: Choline transporter-like protein (CTL) 1 and CTL2 were highly expressed in SIM-A9 cells, and CTL1 and CTL2 were localized in the plasma membrane and mitochondria, respectively. Functional analysis of choline uptake demonstrated the existence of Na+-independent, pH-dependent, and intermediate-affinity choline transport systems. Choline uptake was concentration-dependently inhibited by hemicholinium-3 (HC-3), an inhibitor of choline uptake, and increased by lipopolysaccharide (LPS) and interleukin-4 (IL-4). Expression of the mRNA of M1 microglia markers IL-1ß and IL-6 was increased by LPS, and their effects were suppressed by choline deprivation and HC-3. In contrast, mRNA expression of the M2 microglial marker arginase-1 (Arg-1) was increased by IL-4, and the effect was enhanced by choline deprivation and HC-3. CONCLUSIONS: Our results suggest that inhibition of CTL1-mediated choline uptake in microglia preferentially induces M2 microglia polarization, which is a potential therapeutic approach for inflammatory brain diseases.

Pain Management of Acute and Chronic Postoperative Pain.

Inadequate management of acute postoperative pain is associated with effects related to both physiological and psychological function. Postoperative pain increases the risk of perioperative complications, so postoperative pain should be prevented. Postoperative pain management by sufficient analgesia is important while considering the use of various kinds of analgesics. Insufficient management of postoperative pain may lead to chronic postsurgical pain (CPSP). It is suggested that CPSP is dependent not only upon biological factors but also upon psychological factors, including the type of surgery, age, physical health, mental health, and preoperative pain. As CPSP is a severe complication that may prolong hospitalization and interferes with activities of daily living (ADL) and quality of life (QoL), its prevention of development is paramount. Therefore, in order to prevent the onset of CPSP, it is necessary to craft analgesic management to prevent CPSP during the perioperative period.

Postoperative malignant hyperthermia confirmed by calcium-induced calcium release rate after breast cancer surgery, in which prompt recognition and immediate dantrolene administration were life-saving: a case report.

BACKGROUND: Malignant hyperthermia (MH) is a rare genetic disease characterized by the development of very serious symptoms, and hence prompt and appropriate treatment is required. However, postoperative MH is very rare, representing only 1.9% of cases as reported in the North American Malignant Hyperthermia Registry (NAMHR). We report a rare case of a patient who developed sudden postoperative hyperthermia after mastectomy, which was definitively diagnosed as MH by the calcium-induced calcium release rate (CICR) measurement test. CASE PRESENTATION: A 61-year-old Japanese woman with a history of stroke was hospitalized for breast cancer surgery. General anesthesia was introduced by propofol, remifentanil, and rocuronium. After intubation, anesthesia was maintained using propofol and remifentanil, and mastectomy and muscle flap reconstruction surgery was performed and completed without any major problems. After confirming her spontaneous breathing, sugammadex was administered and she was extubated. Thereafter, systemic shivering and masseter spasm appeared, and a rapid increase in body temperature (maximum: 38.9 °C) and end-tidal carbon dioxide (ETCO2) (maximum: 59 mmHg) was noted. We suspected MH and started cooling the body surface of the axilla, cervix, and body trunk, and administered chilled potassium-free fluid and dantrolene. After her body temperature dropped and her shivering improved, dantrolene administration was ended, and finally she was taken to the intensive care unit (ICU). Body cooling was continued within the target range of 36-37 °C in the ICU. No consciousness disorder, hypotension, increased serum potassium level, metabolic acidosis, or cola-colored urine was observed during her ICU stay. Subsequently, her general condition improved and she was discharged on day 12. Muscle biopsy after discharge was performed and provided a definitive diagnosis of MH. CONCLUSIONS: The occurrence of MH can be life-threatening, but its frequency is very low, and genetic testing and muscle biopsy are required to confirm the diagnosis. On retrospective evaluation using the malignant hyperthermia scale, the present case was almost certainly that of a patient with MH. Prompt recognition and immediate treatment with dantrolene administration and body cooling effectively reversed a potentially fatal syndrome. This was hence a valuable case of a patient with postoperative MH that led to a confirmed diagnosis by CICR.

Anesthetic management of a morbidly obese patient with endometrial cancer during robot-assisted laparoscopic surgery.

BACKGROUND: The number of robot-assisted surgeries being performed has increased in recent years, even in patients with risk factors, such as obesity, owing to advancements in medical technologies. We here report the anesthetic management of a morbidly obese woman who underwent robot-assisted surgery. CASE PRESENTATION: A 44-year-old woman (height, 165 cm; weight, 147 kg; body mass index, 54 kg/m2) was scheduled to undergo robot-assisted laparoscopic hysterectomy for endometrial cancer. Preoperative weight loss and rehearsal of positioning during induction of anesthesia and surgical procedures greatly contributed to the surgical success. Monitoring of oxygen reserve index in combination with SpO2 was useful for appropriate airway and respiratory management. During anesthesia induction, the ramp position using a special commercially available cushion facilitated manual mask ventilation and tracheal intubation. Lung-protective ventilation using a limited tidal volume with moderate PEEP was applied during the robot-assisted surgical procedure. CONCLUSION: We successfully managed anesthesia without any complications.

ORi™: a new indicator of oxygenation.

In the perioperative period, hypoxemia and hyperoxia are crucial factors that require attention, because they greatly affect patient prognoses. The pulse oximeter has been the only noninvasive monitor that can be used as a reference of oxygenation in current anesthetic management; however, in recent years, a new monitoring method that uses the oxygen reserve index (ORi™) has been developed by Masimo Corp. ORi is an index that reflects the state of moderate hyperoxia (partial pressure of arterial oxygen [PaO2] between 100 and 200 mmHg) using a non-unit scale between 0.00 and 1.00. ORi monitoring performed together with percutaneous oxygen saturation (SpO2) measurements may become an important technique in the field of anesthetic management, for measuring oxygenation reserve capacity. By measuring ORi, it is possible to predict hypoxemia and to detect hyperoxia at an early stage. In this review, we summarize the method of ORi, cautions for its use, and suitable cases for its use. In the near future, the monitoring of oxygen concentrations using ORi may become increasingly common for the management of respiratory function before, after, and during surgery.

One-year clinical outcomes of anticoagulation therapy among Japanese patients with atrial fibrillation: The Hyogo AF Network (HAF-NET) Registry.

BACKGROUND: Although anticoagulation therapy could reduce the risk of strokes in patients with atrial fibrillation (AF), large-scale investigations in the direct oral anticoagulant (DOAC) and AF catheter ablation (CA) era are lacking. METHODS: This study was designed as a prospective, multicenter, observational study and a total of 2113 patients from 22 institutions were enrolled in the Hyogo area. RESULTS: The mean age and CHADS2 score were 70.1 ± 10.8 years old and 1.5 ± 1.1, respectively. The follow-up period was 355 ± 43 days. CA was performed in 614 (29%) and DOACs were prescribed in 1118 (53%) patients. Ischemic strokes/systemic embolisms (SEs) and major bleeding occurred in 13 (0.6%) and 17 (0.8%) patients, respectively. New onset dementia, hospitalizations for cardiac events, and all-cause death occurred in eight (0.4%), 60 (2.8%), and 29 (1.4%) patients, respectively. A multivariate analysis demonstrated that persistent AF and the body weight (BW) were associated with ischemic strokes/SEs and major bleeding, respectively (persistent AF: hazard ratio, 9.57; 95%CI, 1.2-74.0; P = .03; BW: hazard ratio, 0.94; 95%CI, 0.90-0.99; P = .02). AFCA history was associated with the cardiac events (hazard ratio, 0.44; 95%CI, 0.20-0.99; P = .04). Age was associated with new onset dementia (hazard ratio, 1.1; 95%CI, 1.0-1.2; P = .03). CONCLUSIONS: In the DOAC and CA era, the incidence of ischemic strokes/SEs, major bleeding and cardiac events could be dramatically reduced in patients with AF. However, some unsolved issues of AF management still remain especially in elderly patients with persistent AF and a low BW.

[Usefulness of dobutamine stress echocardiography in a patient with aortic valve stenosis and left ventricular dysfunction: a case report].

A 76-year-old man with previous antero-septal myocardial infarction and aorto-coronary bypass surgery developed exertional dyspnea. Echocardiography revealed diffuse left ventricular hypokinesis and aortic stenosis with a mean pressure gradient of 29 mmHg. Coronary angiography showed no significant lesions in the bypass grafts and total occlusions of the proximal left anterior descending artery and mid circumflex artery. Dobutamine stress echocardiography was performed to evaluate the severity of aortic stenosis and left ventricular functional reversibility. Administration of dobutamine increased the mean pressure gradients to 48 mmHg and increased the stroke volume by 28% without change in aortic valve area of about 0.5 cm2. We considered that our patient had severe aortic stenosis with contractile reserve. After aortic valve replacement, he improved with better left ventricular function.

Multiple coronary aneurysms resulting from isolated coronary vasculitis in an elderly patient.

An 81-year-old man developed multiple coronary aneurysms, including the left main truncus, that were unexpectedly found by coronary angiography. He had been followed-up for 14 years because of angina pectoris; his initial coronary angiograms in 1985 showed some stenotic segments but no aneurysmal changes. The patient died of gastric cancer in March 2000. On microscopic examination of the coronary arteries, the prominent feature was an inflammatory reaction in the medial layer, comprising chiefly small lymphocytes and plasma cells. The internal and the external elastic membranes were destroyed, presumably causing the aneurysmal dilatation of the vessels. There was a moderate degree of concomitant atherosclerotic fibrointimal thickening. No evidence of vasculitis was seen in sections of the aorta, peripheral arteries, and other major organs. The present case is unique because the cellular infiltrates were confined to the coronary media and although a definite diagnosis was not made, it was probably an atypical form of vasculitic disease; namely, isolated coronary vasculitis.

[Reversible left ventricular dysfunction manifesting as hyperkinesis of the basal and the apical areas with akinesis of the mid portion: a case report].

A 60-year-old man underwent emergent cardiac catheterization because of anterior chest oppression. He had been treated with calcium antagonist and nitrate. Coronary angiography showed no organic stenosis. However, left ventriculography revealed that the basal and the apical areas were hyperkinetic and the mid portion was akinetic. Echocardiography showed that the bizarre-shaped left ventricular dysfunction had completely recovered after a week. Serial electrocardiography demonstrated initial ST-segment elevation in the precordial leads followed by T-wave inversion in II, III, a VF and V4-V6. Coronary artery spasm provocation tests were negative. Endomyocardial biopsy revealed focal myocardial depletion and mild fibrosis. The present case may be an atypical form of tako-tsubo-like left ventricular dysfunction in which the left ventricular contraction is symmetric with both hyperkinetic and akinetic areas.

Concomitant Cushing's syndrome due to adrenal adenoma in a patient with systemic lupus erythematosus.

A 51-year-old woman had been administered 5 mg/day of prednisolone due to systemic lupus erythematosus (SLE). She developed hypertension, hypokalemia and a pathologic pubic fracture during two years before admission. Although iatrogenic Cushing's syndrome was initially suspected, we diagnosed her as concomitant Cushing's syndrome due to a left adrenal tumor. The elevated endogeneous glucocorticoids were evaluated from urinary excretions of 17-hydroxycorticosteroids, which was 2-fold higher than normal and equivalent to 10 mg of prednisolone. After laparoscopic left adrenalectomy, SLE was favorably controlled with 15 mg of prednisolone, the dosage of which was equivalent to the estimated amount of preoperative glucocorticoids.