Challenging treatment of severe hypotension following tracheal intubation in a patient with primary hyperparathyroidism: A case report.

RATIONALE: Primary hyperparathyroidism (PHPT), which is characterized by increased parathyroid hormone secretion, typically manifests as hypercalcemia and hypertension. Here, we report a case of severe hypotension following tracheal intubation during anesthesia induction in a patient with PHPT, in contrast to the expected hypertensive response. PATIENT CONCERNS: A 52-year-old man presented with nausea after eating, leg pain when walking, and headaches. DIAGNOSIS: Based on the blood test and computed tomography results, he was diagnosed with PHPT. INTERVENTIONS: The patient underwent parathyroidectomy under general anesthesia. After induction anesthesia and tracheal intubation, severe acute hypotension and tachycardia suddenly developed. To treat hypotensive shock, we immediately administered ephedrine and phenylephrine and infused Ringer solution. OUTCOMES: The symptoms of hypotensive shock were alleviated by this intervention. LESSONS: We speculate that the cause of his severe hypotension was vasodilation due to the transient release of parathyroid hormone from mechanical stimulation by anesthetic procedures, such as tracheal intubation, combined with hypercalcemia-induced severe dehydration. Moreover, we speculate that fluid resuscitation stabilized his condition and helped achieve a successful surgical outcome. The possibility of severe hypotension after anesthesia induction should be anticipated, and management of cases with severe dehydration should be optimized during the anesthetic management of patients with PHPT.

The Japanese Epidemiologic Study for Perioperative Anaphylaxis, a prospective nationwide study: clinical signs, severity, and therapeutic agents.

BACKGROUND: Diagnosis of perioperative anaphylaxis is difficult because of its non-specific and variable signs and symptoms. Therapeutic agents used to treat anaphylaxis and anaesthesiologist responses also vary depending on the case, which might affect outcomes; however, only a few studies have focused on these factors. METHODS: This prospective study of perioperative anaphylaxis, a part of the Japanese Epidemiologic Study for Perioperative Anaphylaxis, investigated the clinical signs, its severity, therapeutic drugs, epinephrine administration, and anaesthesiologist responses in cases of perioperative anaphylaxis to assess trends and variability. Shock index was used to assess severity of cardiovascular collapse. RESULTS: In 43 patients analysed in this study, cardiovascular signs (88.4%) were the most frequent, followed by skin (81.4%) and respiratory signs (60.5%). The presence of signs increased during the clinical course. The median time from the first signs to diagnosis of anaphylaxis was 10 (5.0-17.8) min. The rates of epinephrine use were 30.2% (unused), 48.8% (i.v.), and 20.9% (i.m.). The median time from diagnosis of anaphylaxis to epinephrine administration was 7 (inter-quartile range: 1.5-8.0) min. Antihistamines and corticosteroids were each used in 69.8% of cases. The worst shock index was higher in patients who received i.v. epinephrine (2.77 [0.90] mean [standard deviation]) than in both no epinephrine use cases (1.35 [0.41]) and i.m. epinephrine cases (1.89 [0.77] (P<0.001]). CONCLUSIONS: The clinical signs and treatments of perioperative anaphylaxis are variable, and the choice regarding epinephrine administration is based on symptom severity. CLINICAL TRIAL REGISTRATION: UMIN000035350.

Utility of 6% hydroxyethyl starch 130/0.4 in oral cancer surgeries with a duration of over 6 hours: A retrospective case-control study.

To evaluate the utility of 6% hydroxyethyl starch (HES) 130/0.4 in oral cancer surgeries with durations over 6 hours. Using a case-control study design, the investigators enrolled patients who underwent oral cancer surgery involving osteotomy or manipulation near the major blood vessels at the Department of Orofacial Surgery in our hospital between 2017 and 2020. The predictor variable was 6% HES130/0.4. Outcomes included in-out balance and other postoperative parameters pertaining to circulatory maintenance (blood loss, urine volume, infusion volume, blood transfusion volume, albumin dose, hemoglobin levels, blood albumin levels, and doses of vasopressors used to maintain blood pressure), as well as pre- and postoperative renal function, pH, bicarbonate levels, and base excess. Changes in renal function were evaluated by assessing blood urea nitrogen and creatinine levels before surgery and at 1 and 7 days postoperatively. The Mann-Whitney U test was used for between-group comparisons, and Student t test was used for intragroup comparisons. The statistical significance was set at P < .05. A total of 65 patients underwent oral cancer surgery with a duration over 6 hours during the study period. The administration of 6% HES130/0.4 at 22.1 ± 7.5 mL/kg/day did not increase blood loss or the blood transfusion volume. Moreover, patients who were administered 6% HES130/0.4 had a significantly larger mean urine volume and infusion volume than those who were not administered 6% HES130/0.4. The infusion therapy could maintain the urine volume and did not worsen renal function. The results of this study showed that administration of 6% HES130/0.4 at a dose lower than 25 mL/kg in patients undergoing oral cancer surgery over 6 hours was effective for circulation maintenance but did not increase the intraoperative blood loss or transfusion volume. This treatment did not cause any dilutional metabolic acidosis or renal dysfunction.

Facial onset sensory and motor neuropathy in a pain clinic outpatient: a case report.

BACKGROUND: Facial onset sensory and motor neuropathy is a very rare sensorimotor disorder characterized by facial onset and gradual progression, with approximately 100 cases reported worldwide in 2020. We report on our experience with a facial onset sensory and motor neuropathy case in our outpatient pain clinic. CASE PRESENTATION: A 71-year-old Japanese man with a previous diagnosis of trigeminal nerve palsy complained of facial paresthesia, cervical pain, and arm numbness. Cervical facet arthropathy was diagnosed initially, but neither pharmacotherapy nor nerve blocking alleviated his symptoms. We suspected bulbar palsy based on the presence of tongue fasciculation, which prompted referral to a neurologist. Based on a series of neurological examinations, facial onset sensory and motor neuropathy was ultimately diagnosed. CONCLUSIONS: Pain clinicians must be mindful of rare diseases such as facial onset sensory and motor neuropathy; if they are unable to make a diagnosis, they should consult with other competent specialists.

Calbindin-Positive Neurons Co-express Functional Markers in a Location-Dependent Manner Within the A11 Region of the Rat Brain.

The A11 region plays a role in numerous physiological functions, including pain and locomotor activity, and consists of a variety of neurons including GABAergic, calbindin positive (Calb+), and dopaminergic (DA) neurons. However, the neurochemical nature of Calb+ neurons and their regulatory role in the A11 region remain largely unknown. In this study, we examined the kind of functional markers co-expressed in the Calb+ neurons using sections from 8-week-old rats. To examine a marker related to classical neurotransmitters, we performed in situ hybridization for vesicular glutamate transporter 2 (vGluT2) or glutamate decarboxylase (GAD) 65 and 67, in conjunction with Calb immunohistochemistry. We found cellular co-expression of Calb with vGluT2 or GAD65/67 throughout the A11 region. Nearly all Calb+/GAD65/67+ neurons were found in the rostral-middle aspect of the A11 region. In contrast, Calb+/vGluT2+ neurons were found predominantly in the middle-caudal aspect of the A11 region. For receptors and neuropeptides, we performed immunohistochemistry for androgen receptor (AR), estrogen receptors (ERα and ERß), and calcitonin gene-related peptide (CGRP). We found that Calb+ neurons co-expressed AR in the rostral aspect of the A11 region in both male and female rats. However, we rarely find cellular co-expression of Calb with ERα or ERß in this region. For CGRP, we found both Calb+ neurons with or without CGRP expression. These results demonstrate that Calb+ neurons co-express many functional markers. Calb+ neurons have a distinct distribution pattern and may play a variety of regulatory roles, depending on their location within the A11 region.

Comparison of Cardiac Repolarization After Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement: A Longitudinal Study.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) has been established as an alternative to surgical aortic valve replacement (SAVR) for high-risk patients. To assess the impact of TAVI on cardiac repolarization, we compared QT dispersion (QTD) and the interval from the peak to the end of the T wave (Tpeak-Tend: TpTe) between the patients who underwent TAVI and those who underwent SAVR and TpTe between the patients who underwent TAVI or SAVR. METHODS: This retrospective study was approved by the ethics committee of Dokkyo Medical University Hospital. The study included 45 patients who underwent TAVI and 45 patients who underwent SAVR. The QT, corrected QT (QTc), QTD, QTc dispersion (QTcD), Tp-Te, Tp-Te/QT, and Tp-Te/QTc were manually measured in standard 12-lead electrocardiogram (ECG) recordings obtained before surgery, immediately after surgery, 1 month, 3 months, and 6 months after surgery and compared between the two groups. RESULTS: No change was observed in RR, QT, QTc, Tp-Te, Tp-Te/QT, and Tp-Te/QTc in the two groups throughout the study. The QTD and QTcD significant decreased immediately after surgery in the TAVI group as compared to the SAVR group (P < 0.001). In contrast, QTD and QTcD in the SAVR group gradually, but not significantly declined 6 months after surgery. CONCLUSIONS: QTD and QTcD immediately decreased after TAVI as compared to SAVR. Our findings indicate that TAVI more rapidly improved dispersion of spatial repolarization than SAVR.

Effect of Methadone on Cardiac Repolarization in Japanese Cancer Patients: A Longitudinal Study.

INTRODUCTION: Methadone is known to prolong the QT interval, which could induce lethal arrhythmias such as torsades de pointes. To determine the risk of ventricular arrhythmias in cancer patients using methadone, we measured QT dispersion (QTD) and Tpeak-Tend (TpTe) before and after methadone administration and evaluated the correlations between methadone dosage and cardiac repolarization. METHODS: We conducted a retrospective observational study with 19 patients undergoing follow-up for cancer pain with methadone. Electrocardiogram (ECG) recordings were obtained from the patients at methadone initiation and 1 week, 1 month, and 2 months later. The QT, corrected QT (QTc), QTD, QTc dispersion (QTcD), TpTe, TpTe/QT, and TpTe/QTc were measured manually via ECG records and analyzed using a repeated measures one-way ANOVA. The correlations between these ECG parameters and each methadone dosage were determined using Spearman's rank correlation coefficient. RESULTS: The QTD, QTcD, TpTe/QT, and TpTe/QTc remained unchanged, while TpTe was prolonged significantly at 2 months (initiation: 82 ± 17 ms; 2 months: 106 ± 20 ms, p = 0.018). In addition, there was a positive correlation between TpTe and methadone dosage (rs = 0.4, p = 0.041). CONCLUSIONS: The findings suggested that small or modest doses of methadone could exert dose-dependent effects on cardiac repolarization in cancer patients. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000034519.

Anesthetic Management for an Adult With Glycogen Storage Disease Type 0.

A 20-year-old woman with glycogen storage disease type 0 (GSD-0) underwent velopharyngeal closure for velopharyngeal insufficiency following palatoplasty. To reduce the risk of complications attributed to GSD-0, general anesthesia was administered using a total intravenous anesthesia (TIVA) technique with propofol and remifentanil, along with supplemental glucose-containing intravenous fluids. Her blood glucose remained stable, intraoperative body temperature ranged from 36.5 to 37.2°C, and the velopharyngeal closure was completed without any adverse events.

[Anesthesia and Anesthesia-related Technology].

Although there is no remarkable change of anesthetics or anesthesia methods in recent years, several new technologies are used for safety management of cardiac, lung or thoracic surgery. Stroke volume variation (SVV) monitoring indicates SVV, a parameter to optimize fluid infusion and is used to avoid edema or congestive heart damage due to over hydration. SmartPilot View, a pharmacokinetic simulator during anesthesia, represents the measured effective site concentration of anesthetics and contributes the optimization of induction and maintenance of anesthesia. Pressure controlled ventilation-volume guarantee (PCV-VG) is a ventilation mode that can secure preset tidal volume even under PCV to avoid hypoxemia and hypercapnia, even when unexpected airway pressure raised. AutoFlow system supplies tidal volume at the lowest airway pressure and has the function of maintaining tidal volume while keeping low airway pressure according to the change of pulmonary compliance. In 2017, we modified the position of cuff air delivery lumen while maintaining the strength and elasticity of double-lumen tube (DLT) made by a company to avoid deflation failure of bronchial cuff by our team.

Three Types of A11 Neurons Project to the Rat Spinal Cord.

The A11 dopaminergic cell group is the only group among the A8-A16 dopaminergic cell groups that includes neurons innervating the spinal cord, and a decrease in dopaminergic transmission at the spinal cord is thought to contribute to the pathogenesis of restless legs syndrome. However, the mechanisms regulating the neuronal activity of A11 dopaminergic neurons remain to be elucidated. Unraveling the neuronal composition, distribution and connectivity of A11 neurons would provide insights into the mechanisms regulating the spinal dopaminergic system. To address this, we performed immunohistochemistry for calcium-binding proteins such as calbindin (Calb) and parvalbumin (PV), in combination with the retrograde tracer Fluorogold (FG) injected into the spinal cord. Immunohistochemistry for Calb, PV, or tyrosine hydroxylase (TH), a marker for dopaminergic neurons, revealed that there were at least three types of neurons in the A11 region: neurons expressing Calb, TH, or both TH and Calb, whereas there were no PV-immunoreactive (IR) cell bodies. Both Calb- and PV-IR processes were found throughout the entire A11 region, extending in varied directions depending on the level relative to bregma. We found retrogradely labeled FG-positive neurons expressing TH, Calb, or both TH and Calb, as well as FG-positive neurons lacking both TH and Calb. These findings indicate that the A11 region is composed of a variety of neurons that are distinct in their neurochemical properties, and suggest that the diencephalospinal dopamine system may be regulated at the A11region by both Calb-IR and PV-IR processes, and at the terminal region of the spinal cord by Calb-IR processes derived from the A11 region.

[Complications Associated with Spinal Cord Stimulation, Radiofrequency and Pulsed Radiofrequency].

Intraoperative complications regarding spinal cord stimulation (SCS) are dural or arachnoidal puncture, spinal or radicular injury and bleeding. Most common complications after SCS are malposition of epidural lead and unexpected device trouble. Other severe complica- tions are infection, hematoma and post dural puncture headache. Complications associated with radiofre- quency and pulsed radiofrequency are bleeding, infec- tion, tissue damage, sensory or motor disturbance and burn injury. And there is known spinal cord infarction as a severe complication. We should explain about the therapeutic procedure and associated complications to patients. Moreover, the immediate assessing of complications and appropriate treatments are necessary.

[The instrument for thermography].

Thermography is an imaging method using the instrument to detect infrared rays emitted from the body surface, and to plot them as a distribution diagram of the temperature information. Therefore, a thermographic instrument can be assumed to measure the skin temperature of the diseased region. Such an instrument is a useful device for noninvasive and objective assessment of various diseases. Examination using a thermographic instrument can assess the autonomic dysfunction by measuring the skin blood flow involved with the sympathetic innervation. Thermography is useful in assisting the determination of the therapeutic effect. However, autonomic dysfunction should be confirmed correctly with the assessment of thermatome that shows abnormal thermal distribution in the region of the disease. Thermography should make noticeable the difference between the body temperature of abnormal and normal sites, and show the alteration of temperature. Monitoring using thermography is useful to determine the effect of sympathetic nerve block. If a thermographic instrument is used, it is important that examiners should understand the function of the instrument, as well as its advantages and disadvantages.

[Buprenorphine transdermal patch (Norspan tape)].

Buprenorphine is a chemically synthesized opioid characterized as the partial mu agonist and kappa antagonist, and transdermal buprenorphine patch will be considered useful as a strong analgesic with fewer psychological side effects in the treatment of chronic non-cancer pain. Use of transdermal buprenorphine should be limited for pain relief of intractable muscle skeletal pain that cannot be alleviated with other analgesics. To avoid severe complication and drug abuse or addiction, assessment of pain and medical history including drug dependence by medical team are important before administration of transdermal buprenorphine. Moreover, side effects such as nausea, vomiting, constipation, erythema and itching, loss of appetite should be treated appropriately. When transdermal buprenorphine is administered to chronic pain patients, physicians must examine the condition of patients regularly at an outpatient clinic. Moreover, decreasing and discontinuation of opioid including transdermal buprenorphine should always be considered during the treatment. Most important objective of chronic pain treatment is to improve QOL and ADL of patients.

Effects of general anesthetics on substance P release and c-Fos expression in the spinal dorsal horn.

BACKGROUND: The authors examined in vivo the effects of general anesthetics on evoked substance P release (primary afferent excitability) and c-Fos expression (neuronal activation) in superficial dorsal horn. METHODS: Rats received saline, propofol (100 mg/kg), pentobarbital (50 mg/kg), isoflurane (2 minimum alveolar concentration), nitrous oxide (66%), or fentanyl (30 µg/kg). During anesthesia, rats received intraplantar 5% formalin (50 µl) to left hind paw. Ten minutes later, rats underwent transcardial perfusion with 4% paraformaldehyde. Substance P release from small primary afferents was assessed by incidence of neurokinin 1 receptor internalization in the superficial dorsal horn. In separate studies, rats were sacrificed after 2 h and c-Fos expression measured. RESULTS: Intraplantar formalin-induced robust neurokinin 1 receptor internalization in ipsilateral dorsal horn (ipsilateral: 54 ± 6% [mean ± SEM], contralateral: 12 ± 2%; P < 0.05; n = 4). Fentanyl, but not propofol, pentobarbital, isoflurane, nor nitrous oxide alone inhibited neurokinin 1 receptor internalization. However, 2 minimum alveolar concentration isoflurane + nitrous oxide reduced neurokinin 1 receptor internalization (27 ± 3%; P < 0.05; n = 5). All agents reduced c-Fos expression (control: 34 ± 4, fentanyl: 8 ± 2, isoflurane: 12 ± 3, nitrous oxide: 11 ± 2, isoflurane + nitrous oxide: 12 ± 1, pentobarbital: 11 ± 2, propofol: 13 ± 3; P < 0.05; n = 3). CONCLUSION: General anesthetics at anesthetic concentrations block spinal neuron activation through a mechanism that is independent of an effect on small primary afferent peptide release. The effect of fentanyl alone and the synergistic effect of isoflurane and nitrous oxide on substance P release suggest a correlative rationale for the therapeutic use of these anesthetic protocols by blocking nociceptive afferent transmitter release and preventing the initiation of cascade, which is immediately postsynaptic to the primary afferent.

Comparison of bupivacaine, ropivacaine, and levobupivacaine in an equal dose and concentration for sympathetic block in dogs.

BACKGROUND AND OBJECTIVES: The aim of this study was to compare the potency of bupivacaine, ropivacaine, and levobupivacaine in an equal dose and concentration for sympathetic block. METHODS: We measured mean arterial pressure, heart rate (HR), and right and left brachial artery blood flow (BABF) before and after cervicothoracic sympathetic block in 24 dogs. The experimental protocol was designed as follows: (1) left cervicothoracic sympathetic block with 1.0 mL of 0.25% bupivacaine (n = 8), (2) left cervicothoracic sympathetic block with 1.0 mL of 0.25% ropivacaine (n = 8), and (3) left cervicothoracic sympathetic block with 1.0 mL of 0.25% levobupivacaine (n = 8). RESULTS: Mean arterial pressure and heart rate did not change significantly throughout the study in either group. Left cervicothoracic sympathetic block with 0.25% bupivacaine increased left BABF significantly from 5 to 100 mins after the block (baseline, 100%; peak at 20 mins after the block, 218% +/- 48%; P < 0.01). Left cervicothoracic sympathetic block with 0.25% ropivacaine increased left BABF significantly from 5 to 100 mins after the block (baseline, 100%; peak at 10 mins after the block, 254 +/- 38%; P < 0.01). Left cervicothoracic sympathetic block with 0.25% levobupivacaine increased left BABF significantly from 5 to 80 mins after the block (baseline, 100%; peak at 20 mins after the block, 183% +/- 38%; P < 0.01). CONCLUSIONS: Ropivacaine may induce a greater increase in vasodilation than bupivacaine and levobupivacaine at the same dose and concentration for sympathetic block in dogs.

Assessment of QT interval and QT dispersion during electroconvulsive therapy using computerized measurements.

BACKGROUND: Electroconvulsive therapy (ECT) used in the treatment of severe psychiatric disorders induces stimulation of the autonomic nervous system with initial parasympathetic outflow immediately followed by a sympathetic response. These responses induce an initial bradycardia, arrhythmias, and hypertension. QT dispersion (QTD), defined as maximal QT interval minus minimal QT interval on 12 leads of the surface electrocardiogram, reflects regional heterogeneity of ventricular repolarization. The effects of electrical stimulus due to ECT on QT interval and QTD are of considerable interest. OBJECTIVE: : This study was designed to investigate the effects of electrical stimulation caused by ECT on RR interval, QT interval, the rate-corrected QT (QTc) interval, QTD, and the rate-corrected QTD (QTcD) under general anesthesia using computerized measurements. METHODS: Thirty psychiatric patients scheduled for ECT were studied under propofol anesthesia. A 12-lead electrocardiogram was monitored to measure parameters. Muscle paralysis was achieved by administering succinylcholine 1 mg/kg intravenously, and the efficacy of ECT was determined by the tourniquet technique. RESULTS: The RR interval and QT interval decreased significantly immediately after electrical stimulus, and returned to the baseline level 1 minute after electrical stimulus. In 25 out of 30 patients, the baseline value of QTc interval was higher than the normal limits, and the QTc interval decreased significantly for 2 minutes after electrical stimulus. In 27 out of 30 patients, the baseline values of QTD and QTcD were higher than the normal limits, and the QTD and QTcD increased significantly from immediately after electrical stimulus to 5 minutes after electrical stimulus. CONCLUSIONS: The QTc interval, QTD, and QTcD, which were associated with increased risks of ventricular arrhythmias, increased significantly before anesthetic induction in patients with major depression. Electrical stimulus during ECT induced further increases of the QTD and QTcD.

[Anesthetic management for pancreaticoduodenectomy in a patient with Charcot-Marie-Tooth disease and liver cirrhosis].

A 68-year-old man was scheduled for pancreaticoduodenectomy under general anesthesia. He was suffering from Charcot-Marie-Tooth disease (CMTD) for 34 years, and complicated with liver cirrhosis. Anesthesia was induced with propofol and fentanyl, and maintained with oxygen-air-sevoflurane and remifentanil. Epidural block was not used because the patient had coagulation abnormality and thrombocytopia. Rocuronium was injected intravenously for tracheal intubation, supplemented as required using an electrical nerve stimulator. The longer duration of action of rocuronium was observed in this case because the patient was complicated with CMTD and liver cirrhosis. We suggest that monitoring neuromuscular function may be necessary to detect subtle residual neuromuscular blockade when rocuronium is used in a patient with CMTD and liver dysfunction.