Clinical significance of assessing cerebral blood volume by time-domain near-infrared spectroscopy in children with congenital heart disease.

BACKGROUND: Despite providing cerebral tissue oxygen saturation (StO2 ), the lack of quantitative information for continuous wave near-infrared spectroscopy (CW-NIRS) is an obstacle in evaluating cerebral hemodynamic conditions. Time-domain NIRS (TD-NIRS) provides both StO2 and cerebral blood volume and has recently become clinically available. AIM: To investigate if the additional monitoring of cerebral blood volume by TD-NIRS facilitates the understanding of cerebral hemodynamic conditions in patients with congenital heart disease. METHODS: Preoperative TD-NIRS values were retrospectively reviewed in patients who underwent a cardiac surgery or catheter examination. We compared the values between patients with single and two ventricles. Moreover, we investigated the association of these values with the demographic and clinical variables. RESULTS: There was no significant difference in StO2 between single ventricle and two ventricles groups (median: 59.9 vs. 54.4, median difference [95% CI]: -4.06 [-9.90 to 2.90], p = .37). However, cerebral blood volume was significantly higher in the single ventricle group (median: 4.68 vs. 2.84, median difference [95% CI]: -2.01 [-2.88 to -1.06], p < .001). Spearman's rank correlation analysis demonstrated an association between StO2 and postmenstrual age (r = 0.35, p = .03). In contrast, cerebral blood volume was correlated with single ventricle physiology (r = 0.62, p < .001), postmenstrual age (r = 0.74, p < .001), central venous pressure (r = 0.38, p = .02), and SaO2 (r = -0.38, p = .02). The multivariable regression analysis identified the postmenstrual age, single ventricle physiology, and SaO2 as independent factors associated with cerebral blood volume. In the logistic analysis, cerebral blood volume was identified as a significant predictor of unfavorable conditions. CONCLUSION: Cerebral blood volume monitoring detected differences in cerebral hemodynamic conditions, related to the age and the type of ventricle physiologies. However, the differences were not apparent in StO2 . The additional monitoring of cerebral blood volume by TD-NIRS would facilitate a better understanding of cerebral hemodynamic conditions in patients with congenital heart disease.

Bispectral Index™ variation during living donor liver transplantation in a child with hepatic encephalopathy: a case report.

BACKGROUND: It is unclear whether perioperative Bispectral Index™ (BIS) monitoring in pediatric cases with acute liver failure (ALF) is effective for evaluation of neurological function. We describe a pediatric patient with hepatic encephalopathy (HE) in whom the BIS value increased from low levels to the normal range during liver transplantation (LT). CASE PRESENTATION: Electroencephalography in a 6-year-old comatose girl diagnosed with ALF and HE who was unresponsive to pain and auditory stimuli revealed continuous slow waves, and hence, emergency LT was performed. Intraoperatively, BIS values remained low until reperfusion. However, BIS value variability increased after reperfusion. She was subsequently discharged without any neurological sequelae. CONCLUSIONS: Low BIS values were considered to reflect the severity of HE. It is possible that improvement of the BIS value and waveform was a reflection of graft function. BIS monitoring might be a good indicator of neurological recovery after LT.

Age-Specific Dose Regimens of Dexmedetomidine for Pediatric Patients in Intensive Care Following Elective Surgery: A Phase 3, Multicenter, Open-Label Clinical Trial in Japan.

OBJECTIVES: To demonstrate the efficacy, safety, and pharmacokinetics of dexmedetomidine as a potential sedative for pediatric surgery patients in the ICU. DESIGN: Phase 3, multicenter, open-label study. SETTING: This study included 61 patients at 13 tertiary hospitals in Japan. PATIENTS: Pediatric patients (≥ 45 wk corrected gestational age to < 17 yr) undergoing intensive care treatment with mechanical ventilation requiring greater than 6 hours estimated duration of sedation following elective cardiac surgery. INTERVENTIONS: Dexmedetomidine was IV administered without a loading dose at age-specific dose regimens 0.2-1.4 (< 6 yr) and 0.2-1.0 µg/kg/hr (≥ 6 yr). The primary endpoint was the percentage of patients who did not require a rescue sedative (midazolam) infusion during mechanical ventilation or for the first 24 hours of a greater than 24 hours ventilation following the commencement of dexmedetomidine administration. MEASUREMENTS AND MAIN RESULTS: Overall, 47 of the 61 patients (77.0%) did not require rescue midazolam. Adverse events were reported in 53 patients (86.9%). Frequently observed adverse events were hypotension (47.5%), bradycardia (31.1%), and respiratory depression (26.2%). Most of these adverse events were mild, a few moderate, and none severe. Although serious adverse events occurred in four patients, including one cardiac tamponade resulting in the withdrawal of dexmedetomidine, none of the adverse events resulted in mortality or were directly related to dexmedetomidine. The plasma dexmedetomidine concentration generally reached the target concentration of 0.3-1.25 ng/mL at 1-2 hours prior to completion of administration or immediately prior to the commencement of tapering. CONCLUSIONS: The age-specific dose regimens of dexmedetomidine without an initial loading dose achieved an adequate sedation level during mechanical ventilation and caused no clinically significant adverse events in the intensive care pediatric patients. These effects were achieved within the therapeutic range of dexmedetomidine plasma concentration and were accompanied by minimal effects on hemodynamics and respiration.

Perioperative management of Fontan operation for the child with panhypopituitarism: a case report.

With the surgical improvement of congenital heart disease, Fontan operation has been applied to many complicated patients in recent years. This is the first report of a child with panhypopituitarism who underwent Fontan operation. A 5-year-old boy was scheduled for Fontan operation. He previously underwent Blalock-Taussig shunt and bidirectional Glenn operations for univentricular heart with double-outlet right ventricle and pulmonary atresia. He was receiving hydrocortisone and 1-desamino-8-D-arginine vasopressin (DDAVP) for panhypopituitarism secondary to removal of craniopharyngioma performed at the age of three years. Although urine output and serum sodium concentration were adequately controlled by adjustment of vasopressin infusion rate during surgery, massive pleural effusions and ascites developed postoperatively, which required several days for control by adjusting the dose of oral DDAVP and normalize the serum sodium level. Intraoperative management of Fontan operation for a patient with panhypopituitarism was controllable by appropriate hormone replacement. However, postoperative fluid management was complicated by the clinical features of panhypopituitarism and Fontan physiology.

Pregabalin for postherpetic itch: a case report.

BACKGROUND: Postherpetic itch has not commonly received attention as a complication of herpes zoster because pain predominates over itch in most patients with herpes zoster. Most cases of postherpetic itch are mild; however, cases of severe postherpetic itch reducing quality of life are rare. CASE PRESENTATION: A 52-year-old woman complained of severe itch in her left pinna and cheek 1 month after the first onset of herpes zoster at the same site. Owing to her scratching, she developed ulcers on her left pinna and cheek. Pregabalin was prescribed, and the itch subsided immediately, with the ulcers disappearing within 1 month. DISCUSSION: Severe itch was thought to be caused by neural injury from herpes zoster. Pregabalin may be a useful treatment option for neuropathic itch induced by herpes zoster.

M1 macrophage infiltration exacerbate muscle/bone atrophy after peripheral nerve injury.

BACKGROUND: Peripheral nerve injury causes limb muscle/bone atrophy, leading to chronic pain. However, the mechanisms underlying muscle/bone atrophy after peripheral nerve injury remain unknown. It was recently reported that M1 macrophages are the main factors responsible for neurogenic inflammation after peripheral nerve injury. We hypothesized that M1 macrophages are important in muscle/bone atrophy after nerve injury. Therefore, we investigated the influence of M1 macrophages on muscle/bone atrophy after nerve injury in mice to prevent muscle/bone atrophy by suppressing M1 macrophages. METHODS: Hindlimb muscle weight and total bone density were measured in a chronic constriction injury (CCI) mouse model. Immunohistochemical analysis and intravital microscopy were performed to visualize hindlimb muscles/bones, and cells were quantified using flow cytometry. We compared M1 macrophage infiltration into muscles/bones and muscle/bone atrophy between macrophage depletion and untreated groups. We also investigated muscle/bone atrophy using administration models for anti-inflammatory and neuropathic pain drugs. RESULTS: Peripheral nerve injury caused significant reduction in muscle weight and total bone density at 1 and 3 weeks after CCI, respectively, compared with that in controls. Osteoclast numbers were significantly higher at 1 week after CCI in the CCI group than in the control group. M1 macrophage infiltration into muscles was observed from 2 h after CCI via intravital microscopy and 1 week after CCI, and it was significantly higher 1 week after CCI than in the control group. In the macrophage depletion group, dexamethasone, pregabalin, and loxoprofen groups, M1 macrophage infiltration into muscles/bones was significantly lower and muscle weight and total bone density were significantly higher than in the untreated group. CONCLUSIONS: M1 macrophage infiltration exacerbates muscle/bone atrophy after peripheral nerve injury. By suppressing M1 macrophages at the neural injury local site, muscle/bone atrophy could be avoided.

High mobility group box 1 can be used to monitor perioperative course in patients with liver cancer.

OBJECTIVE: High mobility group box 1 (HMGB1) is produced by inflammation. Regarding liver injuries, HMGB1 is reportedly involved in liver regeneration. The present study investigated the use of HMGB1 as a postoperative marker of surgical course in patients with liver cancer. METHODS: Patients were enrolled if they had liver cancer, had undergone liver surgery, and did not develop postsurgical complications. Patients who received emergency surgery or patients with unresectable cancerous lesions were excluded. Blood samples were preoperatively obtained as well as at 1 day, 1 week, and 4 weeks following surgery; white blood cell count, serum C-reactive protein, serum albumin, and serum HMGB1 levels were measured. RESULTS: A total of 36 patients were included in this study. HMGB1 levels significantly changed over time, increasing from a median of 7.1 ng/ml (preoperatively) to 13.9 ng/ml at 1 week postoperatively, and then decreased to 6.3 ng/ml at 4 weeks postoperatively. Peak HMGB1 levels were delayed, and elevated HMGB1 levels persisted as compared with the changes in conventional markers. CONCLUSIONS: HMGB1 indicates a unique perioperative inflammatory state in patients with liver cancer. Serum HMGB1 may serve as a marker for monitoring surgical course in patients undergoing surgery for liver cancer.

Influence of the aldehyde dehydrogenase 2 polymorphism on the vasodilatory effect of nitroglycerin in infants with congenital heart disease and pulmonary arterial hypertension.

PURPOSE: The influence of the aldehyde dehydrogenase 2 (ALDH2) gene polymorphism on the pharmacokinetics and haemodynamics of nitroglycerin (GTN) was determined in human subjects. METHODS: Eighteen infants (nine each with and without ALDH2 gene polymorphism) with congenital heart disease and pulmonary arterial hypertension participated in this study. GTN treatment started at a dose of 2 µg/kg/min, and the dose was escalated by 1-2 µg/kg/min until pulmonary vascular resistance (PVR) was reduced by more than 30%. The plasma GTN concentration and PVR were measured at the end of each infusion period. RESULTS: Plasma GTN concentrations were significantly higher in patients with the ALDH2 gene polymorphism than in those without the polymorphism. Conversely, the reduction in PVR was smaller in patients with the ALDH2 gene polymorphism than in those without. CONCLUSIONS: These data suggest that the ALDH2 gene polymorphism influences the pharmacokinetics and haemodynamics of GTN in human subjects.

Intraoperative glycemic control using an artificial endocrine pancreas in a patient with a recurrent pleural solitary fibrous tumor producing insulin-like growth factor 2: a case report.

BACKGROUND: Non-islet cell tumor producing insulin-like growth factor 2 involves hypoglycemia. During tumor resection, intense fluctuation of blood glucose level may occur. An artificial endocrine pancreas has been reported as beneficial for patients with insulinoma as it maintains stable glycemic levels, although scarcely described with insulin-like growth factor 2-releasing tumor. CASE PRESENTATION: An 84-year-old man had a recurrent left pleural solitary fibrous tumor releasing high molecular weight insulin-like growth factor 2 and experienced a frequent syncope accompanied by hypoglycemia. After anesthesia induction, an artificial endocrine pancreas, STG-55, was connected to the patient. Blood glucose level was stable at around 150 mg/dl during the resection surgery. The patient followed an uneventful course and was discharged without any complications. CONCLUSIONS: An artificial endocrine pancreas may have the potential to stabilize the intraoperative blood glucose change in insulin-like growth factor 2-releasing tumor resection.

Mepivacaine-induced anaphylactic shock in a pregnant woman undergoing combined spinal and epidural anesthesia for cesarean delivery: a case report.

BACKGROUND: Anaphylactic shock during pregnancy is a rare but life-threatening event for both the mother and the newborn. CASE PRESENTATION: A 42-year-old woman, who was pregnant with twins, was scheduled for cesarean delivery under combined spinal and epidural anesthesia. An epidural catheter was placed uneventfully. After spinal anesthesia, the patient exhibited skin symptoms and severe hypotension. The patient was diagnosed with anaphylaxis, and subsequently, treatment was started. Fetal heart rate monitoring revealed sustained bradycardia, and it was decided to proceed with cesarean delivery. After delivery, the mother's vital signs recovered. Both infants were intubated due to birth asphyxia. Currently, the twins are 4 years old and exhibit no developmental problems. Clinical examination identified mepivacaine as the causative agent of anaphylaxis. CONCLUSIONS: This case report highlights that upon occurrence of anaphylaxis during pregnancy, maternal treatment and fetal assessment should be started immediately. Indication for immediate cesarean delivery should be considered and a definite identification of the causative factor pursued.

Oxygen reserve index (ORi™) contributes to prediction of hypoxemia and patient safety during tracheal stent insertion using rigid bronchoscopy: a case report.

The oxygen reserve index (ORi™) is a new noninvasive and continuous variable, which represents a moderate hyperoxygenation status, with a unitless scale between 0.00 and 1.00. When percutaneous oxygen saturation (SpO2) exceeds 100%, arterial blood oxygen partial pressure cannot be evaluated without performing arterial blood gas analysis. Because of significant air leakage during rigid bronchoscopy, it is difficult to monitor respiration using capnography, which does not measure end-tidal carbon dioxide (ETCO2) accurately. A 66-year-old man (175 cm, 76.8 kg) with a chief complaint of difficulty in breathing was diagnosed with a thyroid tumor. Computed tomography revealed tracheal stenosis due to direct invasion of the thyroid tumor; therefore, tracheal stenting was planned immediately. After supplying 6 L/min oxygen with a face mask and administering 180 mg of propofol intravenously, the supraglottic airway was intubated. General anesthesia (total intravenous anesthesia) through continuous administration of 6-10 mg/kg/h of propofol and intermittent administration of 50 µg of fentanyl (total 200 µg) preserved spontaneous breathing. During tracheal stent insertion, disconnection between the oxygen supply system and rigid bronchoscopy, and tracheal stent expansion, the ORi tended to decrease before SpO2 decreased. Thus, measuring ORi could prevent hypoxemia during tracheal stent insertion using rigid bronchoscopy.

Current Ventilator and Oxygen Management during General Anesthesia: A Multicenter, Cross-sectional Observational Study.

BACKGROUND: Intraoperative oxygen management is poorly understood. It was hypothesized that potentially preventable hyperoxemia and substantial oxygen exposure would be common during general anesthesia. METHODS: A multicenter, cross-sectional study was conducted to describe current ventilator management, particularly oxygen management, during general anesthesia in Japan. All adult patients (16 yr old or older) who received general anesthesia over 5 consecutive days in 2015 at 43 participating hospitals were identified. Ventilator settings and vital signs were collected 1 h after the induction of general anesthesia. We determined the prevalence of potentially preventable hyperoxemia (oxygen saturation measured by pulse oximetry of more than 98%, despite fractional inspired oxygen tension of more than 0.21) and the risk factors for potentially substantial oxygen exposure (fractional inspired oxygen tension of more than 0.5, despite oxygen saturation measured by pulse oximetry of more than 92%). RESULTS: A total of 1,786 patients were found eligible, and 1,498 completed the study. Fractional inspired oxygen tension was between 0.31 and 0.6 in 1,385 patients (92%), whereas it was less than or equal to 0.3 in very few patients (1%). Most patients (83%) were exposed to potentially preventable hyperoxemia, and 32% had potentially substantial oxygen exposure. In multivariable analysis, old age, emergency surgery, and one-lung ventilation were independently associated with increased potentially substantial oxygen exposure, whereas use of volume control ventilation and high positive end-expiratory pressure levels were associated with decreased potentially substantial oxygen exposure. One-lung ventilation was particularly a strong risk factor for potentially substantial oxygen exposure (adjusted odds ratio, 13.35; 95% CI, 7.24 to 24.60). CONCLUSIONS: Potentially preventable hyperoxemia and substantial oxygen exposure are common during general anesthesia, especially during one-lung ventilation. Future research should explore the safety and feasibility of a more conservative approach for intraoperative oxygen therapy.

Preventative management against thromboembolism using fresh frozen plasma in a coronary artery bypass graft patient with protein S deficiency: a case report.

Protein S deficiency patient is characterized by recurrent thrombosis, and its risk is higher intraoperatively, especially in cardiac surgery involving cardiopulmonary bypass. Two heparin cessation periods are defined in cardiac surgery. One is the period between the cessation of heparin 4 to 5 h before surgery and the heparinization prior to cardiopulmonary bypass. The other is the period between protamine administration and resumption of heparin postoperatively. Because the risk of thromboembolism is high during the period of heparin cessation, other anticoagulants are necessary. Although fresh frozen plasma, rich in protein S, is often used in cardiac surgery for protein S deficiency patients, the most appropriate times and volume of its administration to prevent thromboembolism remain poorly understood. We herein report a case of on-pump coronary artery bypass grafting in a patient with protein S deficiency who received fresh frozen plasma targeting the two heparin cessation periods. Some qualitative measurements to identify the effect of fresh frozen plasma on the protein S level are desirable to evaluate whether our present administration strategy has any beneficial effects on protein S deficiency patients.

Serum creatinine levels and risk of incident type 2 diabetes mellitus or dysglycemia in middle-aged Japanese men: a retrospective cohort study.

OBJECTIVE: To assess the association between low serum creatinine levels and an increased risk of type 2 diabetes mellitus and dysglycemia. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study of 3313 Japanese male workers aged 30-55 years, who underwent annual health check-ups during 2001-2008 and showed no type 2 diabetes mellitus, and underwent follow-up examinations until March 2013. Dysglycemia was defined as a fasting plasma glucose concentration of ≥110 mg/dL (6.1 mmol/L), or a non-fasting plasma glucose concentration of ≥140 mg/dL (7.8 mmol/L). A Cox proportional model was used to calculate HRs and 95% CIs for developing type 2 diabetes mellitus or dysglycemia. RESULTS: During the median 6.7-year follow-up, there were 207 cases of incident type 2 diabetes mellitus and 596 cases of incident dysglycemia, including 115 cases of type 2 diabetes mellitus among the subjects with normal glucose concentrations at baseline. After adjustment for age, body mass index and known diabetes risk factors, the multivariable HR of type 2 diabetes mellitus for the lowest category of serum creatinine (<0.7 mg/dL) vs the highest category (0.9-1.1 mg/dL) was 1.9 (95% CI 1.2 to 2.9; P for trend 0.03). The multivariable HRs of dysglycemia for the lowest category of serum creatinine versus the highest category was 1.5 (95% CI 1.1 to 1.9; P for trend 0.01). CONCLUSIONS: Low serum creatinine levels were associated with an increased risk of type 2 diabetes mellitus and dysglycemia.

Near-infrared spectroscopy might be a useful tool for predicting the risk of vascular complications after pediatric liver transplants: Two case reports.

In patients that have undergone liver transplants, a postoperative reduction in the blood flow of the liver graft represents a critical complication. We recently encountered an interesting phenomenon; that is, we found that the rSO2 level of the liver graft, as measured by NIRS, drops in patients that subsequently require an emergency liver biopsy. An 8-month-old female and an 8-month-old male underwent living donor liver transplants for biliary atresia. In both cases, a reduction in rSO2 was detected before an emergency liver biopsy was required. As a result of biopsy examinations, both patients were diagnosed with acute graft rejection. NIRS might be useful for graft management during the postoperative period in pediatric patients that undergo liver transplantation. After a liver transplant, a reduction in the rSO2 of the graft might be indicative of the onset of vascular complications.

[Present and Future of the Peripheral Nerve Block for Upper Extremities].

Ultrasound guidance has become the standard tech- nique for brachial plexus block. Evidence has been accumulating that the ultrasound-guided brachial plex- us block can provide various advantages such as shorter block performance time, fewer needle passes, reduced incidence of vascular puncture, increased suc- cess rate, and rapid sensory block onset when compared with the conventional nerve localization tech- niques. Real-time ultrasound visualization during the procedure can reduce the amount of local anesthetics and the incidence of complications. Brachial plexus block has a strong analgesic effect with minimal effect on the cardiorespiratory and gastrointestinal systems. Therefore, ultrasound-guided brachial plexus block is a valuable regional anesthetic technique for upper ex- tremity surgery.