Intraoperative fluid management in hepato-biliary-pancreatic operation using stroke volume variation monitoring: A single-center, open-label, randomized pilot study.

TRIAL DESIGN: This investigator-initiated, single-center, open-label, parallel-group, randomized-controlled pilot study was designed to compare the intraoperative fluid balance and perioperative complications in patients undergoing hepato-biliary-pancreatic surgery with or without stroke volume variation (SVV)-guided fluid management. METHODS: Patients who were aged >18 years and underwent elective major hepato-biliary-pancreatic surgery between June 30, 2015, and August 31, 2016 at our center were randomly assigned to receive SVV-guided or conventional fluid therapy. The intervention group used SVV to determine the patients' volume status. The primary outcome was the total fluid balance per body weight per operation time, and the secondary outcomes were the total amount of intravenous infusion per body weight per operation time and the Sequential Organ Failure Assessment score on postoperative day 1. Patients were randomized by a two-block computer-generated assignment sequence. Masking of patients and assessors was conducted. The patients and assessors were each blinded to the details of the trial; however, the clinicians were not. RESULTS: Of the 69 patients who were initially eligible, 60 provided informed consent for participation in the study. After randomization, three patients dropped out of the study because of deviations from the protocol or unexpected hypotension, leaving 28 and 29 patients in the intervention and control groups, respectively. Patients in both groups had similar characteristics at baseline. The median (interquartile range [IQR]) intraoperative fluid balance in the control and SVV groups was 6.2 (IQR, 4.9-7.9) and 8.1 (IQR, 5.7-10.5) ml/kg/h, respectively (P = .103). The administered intravenous infusion was significantly higher in the SVV group (median, 10.9; IQR, 8.3-15.3 ml/kg/h) than in the control group (median, 9.5; IQR, 7.7-10.3 ml/kg/h) (P = .011). On postoperative day 1, the PaO2/FiO2 ratio was lower in the SVV group (median, 266; IQR, 261-341) than in the control group (median, 346; IQR, 299-380) (P = .019). CONCLUSIONS: Use of the SVV-guided fluid management protocol did not reduce intraoperative fluid balance but increased the intraoperative fluid administration and might worsen postoperative oxygenation. TRIAL REGISTRATION: UMIN000018111.

The use of veno-venous extracorporeal membrane oxygenation for massive hemoptysis following a traumatic lung injury: a case report.

BACKGROUND: Published reports regarding the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) for massive hemoptysis following a thoracic injury are still scarce. CASE PRESENTATION: A 34-year-old man developed massive hemoptysis from the right lung after a 2 m fall and being compressed with an iron pipe weighing 500 kg. He was immediately intubated using a double-lumen tube, and one-lung ventilation was started. Endotracheal hemorrhage was controlled by sealing the right lumen. V-V ECMO was initiated to endure the lethal hypoxemia while waiting for the right lung to heal. He came off of V-V ECMO after 17 days and was discharged on foot on day 46. CONCLUSION: The strategy of using V-V ECMO in combination with one-lung ventilation is useful and should be strongly considered to save lethal massive hemoptysis cases following traumatic lung injury.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature.

BACKGROUND: Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates. CASE PRESENTATION: A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death. CONCLUSIONS: In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

A case of lethal giant inguinal hernia.

Several elective surgical managements have been reported regarding giant inguinal hernias (GIH), but no case of death. We here present a fatal case of bilateral GIHs in an extremely obese man with dyspnea. Bilateral GIHs are difficult to recognize in extreme obesity. Moreover, operation is recommended when GIH is diagnosed.

Time-related changes in suicide attempts after the nuclear accident in Fukushima.

PURPOSE: The aim of this study is to assess whether the risk or types of suicide change in Fukushima in the aftermath of a series of disaster, including earthquake, tsunami and nuclear accident in March 2011. METHOD: The clinical records of all patients visited to the medical centre near the nuclear plant from 1 year before to 1 year after the disaster were reviewed (n = 981). Patients with non-fatal suicide attempt were divided into two categories depending on their method of suicide attempt. Standardised mortality ratios were calculated to adjust for changes in demographic profiles. RESULTS: The risk of non-fatal suicide attempts using high-mortality methods was significantly higher for 4 months, by three to four times after the series of disasters, and then decreased. There was no significant increase of non-fatal suicide attempts using low-mortality methods after the disaster. CONCLUSIONS: After such a disaster, immediate psychiatric support may be required because of the increased risk of non-fatal suicide attempts in the immediate aftermath.

Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery?

PURPOSE: Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery. METHODS: We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time. RESULTS: ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p < 0.01), Ps <0.5 (p < 0.001), SI ≥1.0 (p < 0.01), and ASA-PS ≥4E (p < 0.001)]. In particular, ER stay time was inversely related to injury severity up to 120 min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90 min (p < 0.01). CONCLUSIONS: Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.

Surgical airways for trauma patients in an emergency surgical setting: 11 years' experience at a teaching hospital in Japan.

PURPOSE: Airway management of trauma patients during emergency surgeries can be very difficult and presents a challenge for anesthesiologists. Difficult airways are associated with emergency surgical airways (ESA), but little is known about ESA in the operating room. We conducted this study to clarify the present use of ESA for trauma patients in emergency surgery settings. METHODS: We performed a retrospective review of all trauma patients requiring emergency surgery under general anesthesia at our hospital from January 2002 to December 2012, focusing on ESA. RESULTS: During the study period, 15,654 trauma patients were treated at our hospital, of whom 554 (3.5 %) required emergency surgery. Four of these patients (0.72 %) received ESA as definitive airway management. Two patients with severe facial injury and distorted upper airways and 1 patient with penetrating neck trauma received open standard tracheostomy (OST). These three patients received OST as the initial approach to intubation. A fourth OST was performed after several unsuccessful attempts at endotracheal intubation. No cases were classified as "cannot ventilate, cannot intubate" (CVCI), and there were no complications associated with ESA. All cases had good outcomes. Statistical analysis revealed that patients with severe facial trauma (Abbreviated Injury Scale ≥3) received ESA at a significantly higher rate than others (p = 0.015, odds ratio 14.1). CONCLUSION: One of the most important functions of anesthesiologists is risk management. We should recognize risks that can cause CVCI situations, and make proper clinical decisions, including providing ESA, to assure patient safety.

Hypertriglyceridemia as a possible cause of coma: a case report.

INTRODUCTION: Many studies suggest that elevated triglyceride levels are associated with increased long-term risk of stroke, including transient ischemic attacks. In addition, elevated triglyceride levels independently contribute to plasma viscosity and decreased blood flow. However, no consensus has been reached regarding the significance of hypertriglyceridemia as an independent risk factor for ischemic stroke. CASE PRESENTATION: We report the case of a patient admitted to our hospital for sudden onset of coma. Laboratory test results revealed he had high blood glucose (28.2mmol/L), high glycated hemoglobin (11.4 percent), considerably high serum triglyceride levels (171.5mmol/L; type V hyperlipoproteinemia), and high plasma viscosity (1.90mPa/s) with normal ß-hydroxybutyric acid levels. His triglyceride levels decreased after administering intravenous fluids. Our patient's consciousness level improved gradually over three days. All serum lipid levels decreased seven days after admission. CONCLUSIONS: The findings in our patient's case are likely explained by triglyceride-mediated hyperviscosity causing a transient ischemic attack. In the present report we suggest that when several tests do not reveal the cause of stroke-like symptoms, measurement of plasma viscosity may be informative.