Neuraxial anesthesia for patients with severe pulmonary arterial hypertension undergoing urgent open abdominal surgeries: two case reports.

BACKGROUND: There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. CASE PRESENTATION: Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. CONCLUSION: Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery.

Two cases of catheters inserted from the femoral vein straying into the hepatic vein, possibly owing to a Eustachian valve: a case report.

BACKGROUND: In minimally invasive cardiac surgery (MICS) and extracorporeal membrane oxygenation (ECMO), a guidewire is inserted from the femoral vein (FV) into the right atrium. However, rarely, the guidewire or catheter strays into the hepatic vein (HV) because of the inferior vena cava (IVC)-HV angle. We report two cases in which a guidewire and venous cannula from the FV strayed into the HV, likely owing to a Eustachian valve. CASE PRESENTATION: Both patients were women who underwent transesophageal echocardiography-guided FV cannulation. In case 1, a guidewire from the FV strayed into the HV owing to a Eustachian valve. In case 2, ECMO was established postoperatively. Transthoracic echocardiography confirmed the venous cannula had strayed into the HV. Computed tomography indicated IVC-HC angles of 129° (case 1) and 102° (case 2). CONCLUSION: A Eustachian valve can impede devices inserted from the FV and even allow them to stray into the HV.

Abnormally high Patient State Index associated with epicardial pacing: a case report.

BACKGROUND: Anesthesiologists monitor electroencephalography (EEG) intraoperatively to maintain adequate depth of anesthesia. However, the EEG signal is affected by noise and interference. The SedLine® is a brain function monitor with which the Patient State Index (PSI) is calculated. In this study, we report abnormally high PSI values associated with epicardial pacing during open heart surgery. CASE PRESENTATION: A 50-year-old man was scheduled for total arch replacement. Atrial demand pacing was started before weaning from cardiopulmonary bypass. The PSI increased from 30 to 80 soon after the start of pacing, and the EEG waveform showed spikes synchronized with the pacing. As the pacing output was lowered, the spikes on the EEG attenuated and disappeared, and the PSI decreased to < 40. When the pacing output was increased again, the spikes recurred, and the PSI increased again. CONCLUSIONS: Pacemaker spikes may cause contamination of the EEG, resulting in abnormally high PSI values.

Life-threatening rocuronium-induced anaphylactic shock without cutaneous manifestations successfully reversed with sugammadex: a case report.

BACKGROUND: Recognition of rocuronium-induced anaphylaxis is often challenging, owing to its diverse clinical manifestations. Regarding treatment, several reports have described the efficacy of sugammadex, while conflicting reports have also been published. CASE: A 71-year-old man was scheduled to undergo split-thickness skin grafting surgery on his hip. During the induction of general anesthesia, the patient developed profound circulatory collapse without any cutaneous manifestations, which required 40 min of cardiopulmonary resuscitation. Later, the patient developed circulatory collapse again during the induction of anesthesia for tracheostomy surgery, which apparently coincided with the administration of rocuronium. Rocuronium-induced anaphylactic shock was suspected, and the administration of sugammadex resulted in swift recovery of hemodynamics. The basophil activation test revealed a positive reaction to rocuronium. CONCLUSION: The possibility of rocuronium-induced anaphylaxis should be considered when the circulatory collapse coincides with rocuronium administration, even though cutaneous manifestation is absent. Sugammadex can be a treatment option in such atypical cases.

GPC1 specific CAR-T cells eradicate established solid tumor without adverse effects and synergize with anti-PD-1 Ab.

Current xenogeneic mouse models cannot evaluate on-target off-tumor adverse effect, hindering the development of chimeric antigen receptor (CAR) T cell therapies for solid tumors, due to limited human/mouse cross-reactivity of antibodies used in CAR and sever graft-versus-host disease induced by administered human T cells. We have evaluated safety and antitumor efficacy of CAR-T cells targeting glypican-1 (GPC1) overexpressed in various solid tumors. GPC1-specific human and murine CAR-T cells generated from our original anti-human/mouse GPC1 antibody showed strong antitumor effects in xenogeneic and syngeneic mouse models, respectively. Importantly, the murine CAR-T cells enhanced endogenous T cell responses against a non-GPC1 tumor antigen through the mechanism of antigen-spreading and showed synergistic antitumor effects with anti-PD-1 antibody without any adverse effects in syngeneic models. Our study shows the potential of GPC1 as a CAR-T cell target for solid tumors and the importance of syngeneic and xenogeneic models for evaluating their safety and efficacy.