Cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic aortic repair.

BACKGROUND: Cerebrospinal fluid drainage (CSFD) is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair. Although small studies support the use of CSFD, systematic reviews have not suggested definite conclusion and a large-scale study is needed. Therefore, we reviewed medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open and endovascular repair) at multiple institutions to assess the association between CSFD and postoperative motor deficits. METHODS: Patients included in this study underwent descending or thoracoabdominal aortic repair between 2000 and 2013 at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery. We conducted a retrospective study to investigate whether motor-evoked potential monitoring is effective in reducing motor deficits in thoracic aortic aneurysm repair. We use the same dataset to examine whether CSFD reduces motor deficits after propensity score matching. RESULTS: We reviewed data from 1214 patients [open surgery, 601 (49.5%); endovascular repair, 613 (50.5%)]. CSFD was performed in 417 patients and not performed in the remaining 797 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. After propensity score matching (n = 700), mixed-effects logistic regression performed revealed that CSFD is associated with postoperative motor deficits at discharge [adjusted odds ratio (OR), 3.87; 95% confidence interval (CI), 2.30-6.51]. CONCLUSION: CSFD may not be effective for postoperative motor deficits at discharge.

Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement for Aortic Stenosis in Japan　- Analysis of a Nationwide Inpatient Database.

Background: Nationwide data on transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in Japan are scarce. Methods and Results: Using a nationwide inpatient database, we analyzed patients undergoing TAVI (n=8,338) or SAVR (n=16,298) due to aortic stenosis between 2014 and 2017. The annual number of TAVI increased rapidly from 2014 to 2017, particularly in older patients. In-hospital deaths were lower and the length of hospital stay was shorter for patients undergoing TAVI than SAVR. Conclusions: TAVI has been penetrating in Japan as an alternative therapeutic option for aortic stenosis and is associated with acceptable clinical outcomes.

Comparison of two point of care whole blood coagulation analysis devices and conventional coagulation tests as a predicting tool of perioperative bleeding in adult cardiac surgery-a pilot prospective observational study in Japan.

BACKGROUND: It is widely accepted that Point-of Care Test (PoCT) devices are useful in the detection of coagulopathies in situations of massive bleeding such as major cardiac surgery. These devices contribute to the reduction of blood transfusion. However, their implementation remains limited in Japan because of their cost and lack of health insurance support. STUDY DESIGN AND METHODS: Conventional coagulation tests and thromboelastography (TEG)/Sonoclot values were measured in 50 consecutive cardiac surgery cases. Clinical background information such as operative procedures was obtained from electronic medical records, and the theoretical perioperative total blood loss was calculated by measuring the hemoglobin content and total red blood cell transfusion volume. The correlation between perioperative total blood loss and the measured laboratory values or clinical parameters was evaluated by a multivariate linear regression analysis. The risk factors of the total amount of platelet transfusion and postoperative drain bleeding volume were similarly evaluated. RESULTS: No significant association between the estimated perioperative total blood loss (eTBL) and the laboratory measurements including conventional coagulation tests, TEG and Sonoclot was observed. On the other hand, postoperative drain bleeding volume was significantly associated with postoperative Sonoclot CR (p = 0.039) as well as preoperative use of oral anticoagulants and cell saver treated blood volume. Platelet transfusion amount was significantly associated with post-CBP PF and time to peak value of Sonoclot (p = 0.014 and 0.001, respectively). CONCLUSION: Sonoclot measurements may be useful to estimate the risks of postoperative bleeding and platelet transfusion in cardiac surgeries in Japan.

Association Between Motor-Evoked Potentials and Spinal Cord Damage Diagnosed With Magnetic Resonance Imaging After Thoracoabdominal and Descending Aortic Aneurysm Repair.

OBJECTIVES: The authors investigated the association between intraoperative motor-evoked potential (MEP) changes and the severity of spinal cord infarction diagnosed with magnetic resonance imaging (MRI) to clarify the discrepancy between them, which was observed in patients with postoperative motor deficits after thoracic and thoracoabdominal aortic surgery. DESIGN: A multicenter retrospective study. SETTING: Motor-evoked potential <25% of control values was deemed positive for spinal cord ischemia. The severity of spinal cord infarction was categorized into grades A to D based on previous studies using the most severe axial MRI slices. The associations between MRI grade, MEP changes, and motor deficits were examined using logistic regression. PARTICIPANTS: Twenty-three of 1,245 patients (from 1999 to 2013, at 12 hospitals in Japan) were extracted from medical records of patients who underwent thoracic and thoracoabdominal aortic repair, with intraoperative MEP examinations and postoperative spinal MRI. INTERVENTIONS: No intervention (observational study). MEASUREMENTS AND MAIN RESULTS: Motor-evoked potential <25% of control value was associated significantly with motor deficits at discharge (adjusted odds ratio [OR], 130.0; p = 0.041), but not with severity of spinal cord infarction (adjusted OR, 0.917; p = 0.931). Motor deficit at discharge was associated with severe spinal cord infarction (adjusted OR, 4.83; p = 0.043), MEP <25% (adjusted OR, 13.95; p = 0.031), and combined deficits (motor and sensory, motor and bowel or bladder, or sensory and bowel or bladder deficits; adjusted OR, 31.03; p = 0.072) in stepwise logistic regression analysis. CONCLUSION: Motor-evoked potential <25% was associated significantly with motor deficits at discharge, but not with the severity of spinal cord infarction.

Clinical Utility of Intraoperative Motor-Evoked Potential Monitoring to Prevent Postoperative Spinal Cord Injury in Thoracic and Thoracoabdominal Aneurysm Repair: An Audit of the Japanese Association of Spinal Cord Protection in Aortic Surgery Database.

BACKGROUND: Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits. METHODS: Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated whether intraoperative MEP monitoring was associated with postoperative motor deficits at discharge after open and endovascular aortic repair. RESULTS: We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge did not have a significant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69-1.88; P = .624), but with other factors: history of neural deficits (adjusted OR, 6.08; 95% CI, 3.10-11.91; P < .001), spinal drainage (adjusted OR, 2.14; 95% CI, 1.32-3.47; P = .002), and endovascular procedure (adjusted OR, 0.45; 95% CI, 0.27-0.76; P = .003). The sensitivity and specificity of MEP <25% of control value for motor deficits at discharge were 37.8% (95% CI, 26.5%-49.5%) and 95.5% (95% CI, 94.7%-96.4%), respectively. CONCLUSIONS: MEP monitoring was not significantly associated with motor deficits at discharge.

[Somatosensory Evoked Potential during Cardiac Surgery].

Neurologic complications are common in cardiac surgery. The rate of complication can range from 1.6% to 23% for permanent neurologic deficits and from 7% to 61% for transient neurologic deficits. Although several studies have suggested the effectiveness of brain monitoring in reducing postoperative adverse neurologic outcomes, brain monitoring during cardiac surgery has not yet been adopted for routine use. Somatosensory evoked potential (SEP) can provide direct information on the integrity of somatosensory pathway such as SEP elicited by median nerve stimulation in cardiac surgery. An electrode is placed over primary sensory cortex, C3' C4', so called Shagss point. The N20/P25 waveform can be recorded. N20/P25 evoked potentials reflect the perfusion of medial brain circulation. When cerebral blood flow decreases or when brachial plexus is obstructed, N20/P25 amplitude decreases with latency delay. SEP can quickly detect brain ischemia and brachial plexus dysfunction, and it is useful for nervous system monitoring in cardiac surgery.

Effects of preoperative and intraoperative glucose administration on glucose use and fat catabolism during laparotomy under sevoflurane anesthesia in fasted rats.

Preoperative fasting as well as surgical stress significantly modifies metabolisms. Recent studies reported the possible advantageous effects of glucose administration on perioperative metabolisms; however, the underlying mechanisms have not been fully elucidated. Rats were allocated to three groups. During the fasting period, groups A and B were administered water, but group C was administered glucose. During laparotomy and the insulin tolerance test (ITT) under sevoflurane anesthesia, group A was administered saline, but groups B and C were administered glucose. During laparotomy, group C showed higher glucose levels and lower ß-hydroxybutyrate (ß-OHB) levels than group A, and group B showed more decreases in ß-OHB levels than group A without differences in changes in glucose levels. Insulin levels and insulin sensitivity during laparotomy were similar among the three groups. No significant difference in insulin sensitivity was also confirmed in ITT. In conclusion, perioperative glucose administration suppresses lipolysis without affecting insulin secretion and sensitivity.

Effects of preoperatively administered carbamazepine and phenytoin on rocuronium-induced neuromuscular block under sevoflurane anesthesia: a retrospective clinical study.

We examined the effects of preoperatively administered phenytoin and carbamazepine on rocuronium-induced neuromuscular block under sevoflurane anesthesia in this retrospective clinical study. When compared to patients without anticonvulsant therapy (n = 16), the recovery index (i.e., the time required from 25% of spontaneous return of T1 to 75% of spontaneous return of T1) was significantly lower in patients with anticonvulsant therapy using carbamazepine and/ or phenytoin (n = 17); however, no significant dose-dependent effects of carbamazepine as well as phenytoin on the recovery index were detected. Further studies are required to elucidate the mechanisms underlying the modifying effects of carbamazepine and phenytoin on pharmacokinetics and pharmacodynamics of rocuronium.

Stroke education for multidisciplinary medical personnel in a rural area of Japan for promotion of hospital visit of acute stroke patients.

BACKGROUND: There are few studies of stroke education suitable for multidisciplinary medical personnel. A reorganization of the management of acute stroke and stroke education for multidisciplinary medical personnel started since 2013 in our hospital located in a rural area of Japan. This study aimed to examine the effect of our stroke education on changing the number of visits of acute stroke patients to our hospital and to test the stroke knowledge of medical personnel. METHODS: The stroke education, composed of a 20-minute lecture, was given by a stroke neurologist to 217 medical personnel (age, 49 ± 10 years; male, 70%). Posters printed with the FAST message were given to the participants at the end of the lesson: F, facial drooping; A, arm numbness or weakness; S, slurred speech or difficulty speaking or understanding; T, a time to call an ambulance. Participants completed questionnaires on stroke knowledge at baseline and 3 months after the lesson. RESULTS: The number of participants who remembered correctly the FAST mnemonic at 3 months was significantly higher than at baseline (78 vs. 90%, P = .006). The correct answer rate for stroke symptoms other than FAST such as vision loss was approximately 50% at 3 months. The number of visits of acute stroke patients to our hospital, particularly patients with transient ischemic attack, increased significantly compared with that before the stroke education. CONCLUSIONS: Our stroke education method using the FAST mnemonic designed for multidisciplinary medical personnel improved their stroke knowledge. Reorganization of the management of acute stroke and greater stroke knowledge for medical staff are necessary to increase the visits of acute stroke patients in the rural areas.

Comparison of mechanisms underlying changes in glucose utilization in fasted rats anesthetized with propofol or sevoflurane: Hyperinsulinemia is exaggerated by propofol with concomitant insulin resistance induced by an acute lipid load.

The effects of anesthesia with sevoflurane and with propofol on glucose utilization in rats were investigated. Sevoflurane significantly impairs glucose utilization whereas propofol does not. Both insulin secretion and sensitivity affect glucose utilization. Propofol is hydrophobic, and anesthesia with this agent is always accompanied by an acute lipid load, which can exaggerate insulin resistance. The role of the acute lipid load in the effects of anesthesia with sevoflurane and propofol on glucose utilization in fasted rats was investigated. Rats were allocated to groups anesthetized with sevoflurane and infused with physiological saline (group S) or 10% w/v lipid (group SL), or those anesthetized with propofol (group P). Intravenous glucose tolerance tests and insulin tolerance tests were then performed to measure glucose utilization, and blood glucose, plasma insulin, and plasma TNF-α levels were measured. In the intravenous glucose tolerance test, groups SL and P showed significantly higher plasma insulin levels than group S, and group P showed significantly higher plasma insulin levels than group SL. In the insulin tolerance test, groups SL and P showed insulin resistance compared to group S, but no significant difference was observed between groups SL and P. In summary, propofol anesthesia enhances insulin secretion and concomitantly exaggerates insulin resistance, compared with sevoflurane anesthesia. Propofol appears to be the main cause of hyperinsulinemia, and the acute lipid load exaggerates insulin resistance.

Glucose administration during volume resuscitation using dextran-40 from hemorrhagic shock ameliorates acid/base-imbalance in fasted rats under sevoflurane anesthesia.

The hyperglycemic response is an important prognostic factor for survival after hemorrhage. In this study, we investigated the effects of glucose administration during volume resuscitation from hemmorhagic shock in fasted rats under sevoflurane anesthesia on hemodynamics, acid/base-balance and glucose metabolism. Hemorrhagic shock was induced in rats by withdrawing 25 mL/kg of blood. For volume resuscitation, rats in group-Dextran[saline] and group-Dextran[glucose] underwent infusion therapy using 10% dextran-40 dissolved in physiological saline and 10% dextran-40 dissolved in 5% glucose, respectively. Arterial blood was sampled just before blood withdrawal, immediately after blood withdrawal, immediately after volume resuscitation and at 30 min after volume resuscitation for arterial gas analyses and measurement of plasma insulin levels. After volume resuscitation, group-Dextran[glucose] showed similar arterial blood pressure, significantly lower heart rate, similar arterial PO2 and similar hematocrit in comparison with group-Dextran[saline], suggesting that there was no particular difference in oxygen demand/supply-balance between the two groups. After volume resuscitation, group-Dextran[glucose] showed significantly higher arterial pH, similar arterial PCO2, significantly higher bicarbonate levels and significantly higher base excess in comparison with group-Dextran[saline], suggesting that metabolic acidosis is a cause of the difference in acid/ base-balance between the two groups. After volume resuscitation, group-Dextran[glucose] showed significantly higher glucose levels, significantly higher insulin levels and significantly lower lactate levels in comparison with group-Dextran[saline]. At 30 min after volume resuscitation, base excess correlated significantly with lactate levels. These results suggest that glucose administration during volume resuscitation using dextran-40 from hemorrhagic shock ameliorates acid/base-imbalance associated with hyperlactatemia in fasted rats under sevoflurane anesthesia.

Glucose use in fasted rats under sevoflurane anesthesia and propofol anesthesia.

BACKGROUND: We previously reported the marked differences in the effects of sevoflurane anesthesia and propofol anesthesia on glucose use in fed rats; however, we could not elucidate mechanisms underlying the differences. METHODS: We used fasted rats in this study. After surgical preparation under sevoflurane anesthesia, rats were divided into 3 groups: awake rats, rats under sevoflurane anesthesia, and rats under propofol anesthesia. All rats underwent the IV glucose tolerance test (IVGTT); 0.5 g/kg glucose was administered IV to rats. Just before IVGTT, some rats were pretreated with glibenclamide or diazoxide. We measured glucose, insulin, tumor necrosis factor-α (TNF-α), and high molecular weight adiponectin levels during IVGTT and calculated the quantitative insulin sensitivity check index (QUICKI) using glucose and insulin levels before glucose administration in each rat. RESULTS: Before glucose administration, rats under sevoflurane anesthesia showed similar glucose and insulin levels with significantly higher QUICKI compared with awake rats, while rats under propofol anesthesia showed similar glucose levels and significantly higher insulin levels with significantly lower QUICKI compared with awake rats. After glucose administration, rats under sevoflurane anesthesia showed significantly higher glucose levels and similar insulin levels compared with awake rats, while rats under propofol anesthesia showed similar glucose levels and significantly higher insulin levels compared with awake rats. Before glucose administration, TNF-α levels in rats under sevoflurane anesthesia and rats under propofol anesthesia were similar to those in awake rats. After glucose administration, TNF-α was undetectable in all awake rats and all rats under sevoflurane anesthesia, whereas TNF-α was detectable in all rats under propofol anesthesia; TNF-α levels in rats under propofol anesthesia were significantly higher than those in awake rats. High molecular weight adiponectin levels in rats under sevoflurane anesthesia and rats under propofol anesthesia were similar to those in awake rats throughout the experimental period. In rats under sevoflurane anesthesia, glibenclamide significantly decreased glucose levels and significantly increased insulin levels; however, diazoxide produced no significant effects on glucose and insulin levels. In rats under propofol anesthesia, glibenclamide significantly decreased glucose levels and significantly increased insulin levels, while diazoxide significantly decreased glucose levels without changing insulin levels. CONCLUSIONS: Sevoflurane anesthesia attenuates glucose-induced insulin secretion without affecting basic insulin secretion, while propofol anesthesia enhances insulin secretion. Propofol anesthesia exaggerates insulin-resistive conditions, whereas sevoflurane anesthesia dose not impair insulin sensitivity; there may be a possible association of TNF-α with insulin-resistive conditions under propofol anesthesia.

Increased cerebrovascular resistance after retrograde cerebral perfusion: a Doppler study.

Deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (RCP) under high central venous pressure (CVP) is often used in aortic arch surgery under cardiopulmonary bypass (CPB). We hypothesized that DHCA with RCP under high CVP causes cerebral vascular compression because of increased perivascular pressure due to extravasation of fluid into intracranial tissue. In a retrospective study, we evaluated the pulsatility index (PI) and resistance index (RI) of the internal carotid arteries (ICA) and external carotid arteries (ECA) before and after CPB in 15 patients who underwent DHCA/RCP (group 1) and 17 patients who underwent regular CPB without DHCA/RCP (group 2). Both indices are known to reflect vascular resistance distal to the measurement point. The PI and RI of the ICA increased significantly after the procedure in group 1 but did not change in group 2. The PI and RI of the ECA did not change in either group. In group 1, the rate of increase in PI and RI correlated with the duration of RCP, which was significantly higher in patients who had postoperative delirium than in patients who did not experience postoperative delirium. As increases in PI/RI after DHCA/RCP occurred only in the ICA, we concluded that the changes were due to compression of vessels as a result of increased perivascular pressure. The greater increase in the PI/RI in patients who experienced postoperative delirium indicates that increased perivascular pressure plays a role in the occurrence of postoperative delirium after DHCA/RCP.

[Case of bladder perforation due to the obturator nerve reflex during transurethral resection (TUR) of bladder tumor using the TUR in saline (Turis) system under spinal anesthesia].

Bladder perforation due to the obturator nerve reflex (ONR) is a serious complication during TUR of bladder tumor using the conventional TUR system; requiring monopolar electrocautery and non-conductive solution as perfusate. Recently, the TURis system, which employs bipolar electrocautery and physiological saline as perfusate, has been developed. Electrical resistance of physiological saline and human tissues are approximately 40 and 500 omega, respectively. Thus, theoretically, electrical current flows between the resection loop and the recovery electrode integrated in the outer sleeve of the endoscope, without forming electrical circuit in the patient's body; suggesting possible elimination of the ONR. Here we describe a case of bladder perforation during surgery using the TURis system; the ONR was exaggerated during the procedure to stop bleeding at the lateral wall using bipolar electrocautery. In addition to this case, there have been a few reports of the ONR during surgery using the TURis system, and it is reported that weak electrical current may pass through the patient's body in the TURis system. We consider that evaluation of the necessary precautions, such as the obturator nerve block, for the prevention of the ONR is important even in the surgery using the TURis system.

[Anesthetic management for emergency laparotomy in an adult patient with Eisenmenger syndrome: a case report].

There are few clinical reports concerning anesthetic management for patients with Eisenmenger syndrome requiring non-cardiac surgery. The risk of morbidity and mortality associated with non-cardiac surgery in patients with Eisenmenger syndrome is considerable. During anesthetic management for these patients, careful circulatory and respiratory managements to avoid several factors related to surgery and anesthesia that can potentially increase right to left shunt flow are required. Therefore, it is very important to maintain cardiac output to prevent a decrease in systemic vascular resistance and an increase in pulmonary vascular resistance. For this purpose, combination of intravenous administration of inotropes such as milrinone and dobutamine, and vasopressors such as norepinephrine, might have clinical efficacy. Here we describe an anesthetic management for a 50-year-old woman with a ventricular septal defect and Eisenmenger syndrome undergoing emergency laparotomy. We considered that sufficient fluid therapy and adequate administration of inotropes and vasopressors, based on strict hemodynamic assessment using direct arterial and central venous pressure monitoring, arterial blood gas analysis, and transesophageal echocardiography during general anesthesia, might have contributed to the uneventful perioperative course of the patient.

Orexin a elicits arousal electroencephalography without sympathetic cardiovascular activation in isoflurane-anesthetized rats.

UNLABELLED: We studied the effects of intracerebroventricular injection of the novel neuropeptide orexin A on electroencephalogram (EEG) and autonomic nervous system activity in rats under isoflurane anesthesia. The administration of orexin A changed burst suppression patterns to arousal patterns on the EEG at 1.0 minimum alveolar anesthetic concentration (MAC) isoflurane and decreased the burst suppression ratio at 1.5 MAC isoflurane. However, orexin A did not influence the heart rate or mean arterial blood pressure at either isoflurane concentration. These findings demonstrated that orexin A elicited anesthetic arousal under isoflurane anesthesia in terms of EEG pattern without sympathetic cardiovascular activation in the rat. IMPLICATIONS: The novel neuropeptides orexins induce arousal associated with activation of the sympathetic nervous system in conscious rats. It is not known whether orexins affect the electroencephalogram (EEG), autonomic nerve activity, or both under anesthesia. Orexin A induced EEG arousal without sympathetic cardiovascular activation in the isoflurane-anesthetized rat. Orexin A might influence the depth of anesthesia.

Isoflurane ameliorates the posthypoxic deoxygenation of the rat brain--the role of cell adhesion molecules of polymorphonuclear leukocytes.

One of the serious problems that occurs after cardiopulmonary resuscitation is brain posthypoxic/ischemic deoxygenation. However, there has been no report concerning the effect of isoflurane (ISO) on the brain oxygenation during hypoxia-reoxygenation in relation to cell adhesion molecules (CD11b) in polymorphonuclear leukocyte. Rats were anesthetized with a low concentration of ISO (0.5 MAC: low ISO) or high concentration of ISO (1.5 MAC: high ISO) and brain oxygenation was detected by near infrared spectroscopy during 10-min hypoxia (5% O(2)) and a subsequent 120-min reoxygenation period. Hypoxia induced a decrease in oxyhemoglobin (HbO(2)) and an increase in deoxyhemoglobin (Hb). Reoxygenation induced a significant decrease in total hemoglobin (tHb) and HbO(2) with low ISO, but not with high ISO. The changes in Hb were minimal during reoxygenation in both groups. CD11b increased during reoxygenation with low ISO anesthetization, but not with high ISO. A significant negative correlation was observed between CD11b and two of the measured oxyparameters, HbO(2) and tHb, during reoxygenation at low ISO, but not at high ISO. These findings suggest that brain deoxygenation during hypoxia-reoxygenation is partly related to the expression of CD11b. We conclude that ISO modifies the brain circulation at least in part through attenuating the expression of CD11b during hypoxia-reoxygenation.