Cardiac Arrest During the Medical Management of Left Ventricular Outflow Tract Obstruction Following the Transcatheter Aortic Valve Implantation.

Systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction are complications following transcatheter aortic valve implantation and can lead to hemodynamic collapse. Medical management for those complications is usually centered on a reduction in left ventricular contractility with negative inotropes. An 88-year-old woman underwent transcatheter aortic valve implantation for severe aortic stenosis. Hemodynamic collapse and exacerbation of mitral regurgitation occurred immediately after valve implantation. For suspected left ventricular outflow tract obstruction, medical management centered on negative inotropes was performed. Hemodynamics and left ventricular outflow tract obstruction improved over time; however, the oxygen supply-demand imbalance progressed. On postoperative day 5, the patient suddenly went into pulseless electrical activity. Cardiopulmonary resuscitation was performed for three minutes, resulting in the return of spontaneous circulation. Subsequent refractory hypotension and oxygen supply-demand imbalance improved with continuous infusion of adrenaline, dobutamine, and phenylephrine. Her hemodynamics remained stable after she was weaned off the pressor infusions, and negative inotropes were not required again. In summary, the cause of cardiac arrest was possibly due to excessive negative inotropic effects even though the effects contributed to improvement of left ventricular outflow tract obstruction. Anesthesiologists and intensivists should recognize the risk of cardiac arrest induced by negative inotropic effects and use negative inotropes with rigorous hemodynamic monitoring, even when left ventricular outflow tract obstruction is treated effectively.

Anesthetic Management of a Patient With Central Core Disease Undergoing Thoracoscopic Lung Resection: The Importance of Neuromuscular Monitoring at the Masseter Muscle.

Central core disease is a rare muscular disorder in which anesthetic considerations for the prevention of malignant hyperthermia and for avoidance of residual neuromuscular block are required. A 63-year-old woman with central core disease underwent thoracoscopic sublobar lung resection under total IV anesthesia with a prepared anesthetic workstation. The rocuronium-induced neuromuscular block was monitored by using acceleromyography at the left adductor pollicis muscle and the right masseter muscle. The recovery of neuromuscular block at the masseter was slower than that at the adductor pollicis. The patient showed no symptoms of malignant hyperthermia and residual neuromuscular block and had an uneventful postoperative course. In the present case, malignant hyperthermia was successfully prevented with general anesthesia that is free of triggering agents using a prepared anesthetic machine. The authors speculate that the masseter may be an auxiliary site for neuromuscular monitoring to ensure recovery from neuromuscular block in patients with central core disease.

Comparison of the Pulse Wave Transit Time Method and an Arterial Pressure-Based Cardiac Output System for Measuring Cardiac Output Trends During Laparotomy Without Postural Change

Objective: Perioperative intravascular volume can be optimised by identifying predictors of fluid responsiveness. This study compared the estimated continuous cardiac output (esCCO) system for non- invasive measurement and an arterial pressure-based cardiac output (APCO) system for detecting exact changes in cardiac output (CO) among patients undergoing laparotomy without postural change. Methods: This study was performed at Toho University Omori Medical Centre in Japan from April 2016 to July 2016 and included 26 adult patients undergoing elective laparotomy lasting > 2 h without postural change. We evaluated both interchangeability and dynamic trend. After entering the biometric data (age, sex, height, weight, heart rate, pulse wave transit time, and blood pressure), the esCCO device was calibrated. All patients were also monitored with the APCO system. Data were analysed and compared for 12 adult patients using Bland­Altman analysis and polar plots. Results: The CO value obtained with esCCO was 0.75 ± 0.86 L/min (percentage error: 41%) lower than that obtained with the APCO system. Polar plotting revealed that the mean angular bias was 3.5°, and the radial limit of agreement was 28.3°. Conclusion: This study demonstrated that data obtained using esCCO are not interchangeable with those obtained using the APCO system. The trending ability of the esCCO device was deemed good among patients undergoing laparotomy without postural change.

Relationship between outcome in acute stroke patients and multiple stroke related scores obtained after onset of stroke.

[Purpose] The purpose of this study is to examine the effectiveness of a stroke-related scale with regard to outcome, onset, and timing of stroke patients. [Participants and Methods] The participants included 583 out of 996 patients who were admitted to the stroke care unit.The outcomes and 3 stroke scale (National Institutes of Health Stroke Scale: NIHSS, Functional Independence Measure: FIM, modified Rankin Scale: mRS) scores immediately at hospitalization, on day 7 after onset, and on day 30 after onset were investigated. This study was analyzed using a generalization linear model with a binomial distribution. The comparisons between outcomes were made in terms of home discharge versus convalescence, and convalescence versus hospital transfer. [Results] Comparisons of home discharge versus convalescence hospital transfer showed a significant difference in the NIHSS and mRS scores at the time of hospitalization, and a significant difference in the NIHSS scale score on day 7 after onset. In comparisons between convalescence and hospital transfer, significant differences were observed in NIHSS and FIM scores at hospitalization, and the FIM scale score showed significant differences on day 7 and day 30. [Conclusion] The study suggested the efficacy of using multiple scales for prediction of stroke outcome with higher accuracy.

[A case of anaphylaxis induced by gelatin-contained gel capsule cold medicine].

We report here a 20-year old woman who referred to our clinic for identify the responsible antigen of anaphylaxis. Five days before the reaction, she had a cold and had taken a gel capsule cold medicine, Stona IB Gel®. On the day of the reaction, she took a dose of Stona IB Gel® after eating yogurt. Five minutes after oral administration, she developed a heat sensation and pruritus on her neck, with flushing, abdominal pains, breathing difficulties, and syncope. The specific IgE antibodies measured by ImmunoCAP® were all negative except for gelatin. Prick-prick skin testing revealed positive responses to Stona IB Gel®, gelatin KS and gelatin RP600, of which the latter two were included in the Stona IB Gel® capsule. From these test results, she was diagnosed with anaphylaxis due to gelatin, and to date she has had no further allergic symptoms since avoiding foods containing gelatin. In infancy she had received four vaccinations against diphtheria, pertussis and tetanus, which contained gelatin as a stabilizer. However, she had not developed allergic symptoms until this time. We hypothesize that she might be sensitized to gelatin by taking Stona IB Gel® during the preceding 4 days. This is the first case of anaphylaxis from the ingestion of an oral medication containing gelatin in Japan. Allergic reactions to gelatin are comparatively rare, but according to the past reports, the reactions were severe. Since many kinds of foods, cosmetics, pharmaceutical products, and medication contain gelatin, it is important to be aware of gelatin allergy.

Large-scale survey of adverse reactions to canine non-rabies combined vaccines in Japan.

Canine non-rabies combined vaccines are widely used to protect animals from infectious agents, and also play an important role in public health. We performed a large-scale survey to investigate vaccine-associated adverse events (VAAEs), including anaphylaxis, in Japan by distributing questionnaires on VAAEs to veterinary hospitals from April 1, 2006 through May 31, 2007. Valid responses were obtained for 57,300 vaccinated dogs at 573 animal hospitals; we obtained VAAEs information for last 100 vaccinated dogs in each veterinary hospital. We found that of the 57,300, 359 dogs showed VAAEs. Of the 359 dogs, death was observed in 1, anaphylaxis in 41, dermatological signs in 244, gastrointestinal signs in 160, and other signs in 106. Onset of VAAEs was mostly observed within 12h after vaccination (n=299, 83.3%). In this study, anaphylaxis events occurred within 60 min after vaccination, and about half of these events occurred within 5 min (n=19, 46.3%). Furthermore, where anaphylaxis was reported, additional information to support the diagnosis was obtained by reinvestigation. Our resurvey of dogs with anaphylaxis yielded responses on 31 dogs; 27 of these demonstrated collapse (87.1%), 24 demonstrated cyanosis (77.4%), and both signs occurred in 22 (71.0%). Higher rates of animal VAAEs, anaphylaxis, and death were found in Japan than in other countries. Further investigations, including survey studies, will be necessary to elucidate the interaction between death and vaccination and the risk factors for VAAEs, and thus develop safer vaccines. Moreover, it may also be necessary to continually update the data of VAAEs.

Induction of SCEs in CHL cells by dichlorobiphenyl derivative water pollutants, 2-phenylbenzotriazole (PBTA) congeners and river water concentrates.

We recently identified dichlorobiphenyl (DCB) derivatives and 2-phenylbenzotriazole (PBTA) congeners as major mutagenic constituents of the waters of the Waka River and the Yodo River system in Japan, respectively. In this study we examined sister chromatid exchange (SCE) induction by two dichlorobiphenyl derivatives, 3,3'-dichlorobenzidine (DCB, 4,4'-diamino-3,3'-dichlorobiphenyl) and 4,4'-diamino-3,3'-dichloro-5-nitrobiphenyl (5-nitro-DCB); three PBTA congeners, 2-[2-(acetylamino)-4-[bis(2-methoxyethyl)amino]-5-methoxyphenyl]-5-amino-7-bromo-4-chloro-2H-benzotriazole (PBTA-1), 2-[2-(acetylamino)-4-[N-(2-cyanoethyl)ethylamino]-5-methoxyphenyl]-5-amino-7-bromo-4-chloro-2H-benzotriazole (PBTA-2), and 2-[2-(acetylamino)amino]-4-[bis(2-hydroxyethyl)amino]-5-methoxyphenyl]-5-amino-7-bromo-4-chloro-2H-benzotriazole (PBTA-6); and water concentrates from the Waka River in Chinese hamster lung (CHL) cells. Concentration-dependent induction of SCE was found for all DCBs and PBTAs examined in the presence of S9 mix, and statistically significant increases of SCEs were detected at 2 microg per ml of medium or higher concentrations. SCE induction of MeIQx was examined to compare genotoxic activities of these water pollutants. According to the results, a ranking of the SCE-inducing potency of these compounds is the following: 5-nitro-DCB approximately MeIQx>PBTA6>PBTA-1 approximately PBTA-2>DCB. Water samples collected at a site at the Waka River showed concentration-related increases in SCEs at 6.25-18.75 ml-equivalent of river water per ml of medium with S9 mix. The concentrations of 5-nitro-DCB and DCB in the river water samples were from 2.5 to 19.4 ng/l and from 4100 to 18,900 ng/l, respectively. However, these chemicals showed only small contribution to SCE induction by the Waka River water.