Severe acute cholecystitis successfully treated with endoscopic nasobiliary drainage tube insertion: A case report.

In this report, we present a case of a patient with bile peritonitis caused by gallbladder perforation associated with acute cholecystitis, which required intensive postoperative care. The patient was a woman in her 40s who presented with abdominal pain. Upon examination, she was diagnosed as having acute cholecystitis and bile peritonitis caused by gallbladder perforation. Subsequently, a partial cholecystectomy, omental pack, and drainage were performed. Initially, her bile duct enzyme levels improved; however, they subsequently increased again. An endoscopic nasobiliary drainage tube was inserted, and thereafter, a decrease in inflammatory response and bile duct enzyme levels was observed. During the course of treatment, respiratory failure and renal impairment occurred, necessitating mechanical ventilation management and continuous hemodiafiltration. In patients with severe acute cholecystitis, in addition to treating the underlying condition, it is crucial to perform procedures perioperatively, in anticipation of the development of additional organ dysfunctions postoperatively.

A Case of Nerve Root Radiofrequency Thermocoagulation for Pain Due to Pleural Metastasis of Lung Cancer Leading to Improvement in the Patient's Quality of Life.

Advances in medicine have made long-term survival of cancer patients possible. Hence, it is now necessary to consider how to approach common symptoms, such as cancer-related pain, in these patients. In this study, we describe a lung cancer patient in whom relief of intractable thoracic pain caused by pleural metastasis was achieved through thoracic radiofrequency thermocoagulation (RF), improving his quality of life (QOL). The patient was a man in his 70s with right upper lobe lung cancer, left 9th -11th rib metastasis, and left thoracic pain associated with parietal pleural metastasis. The patient experienced insomnia and weight loss due to poor appetite caused by opioid analgesics and inadequate pain control. Therefore, RF was performed as interventional treatment, resulting in a decrease in the numerical rating scale score from 10/10 to 2/10, and an improvement in QOL. In cases wherein long-term survival is expected, a long-term treatment plan for chronic cancer-related pain, which has a tendency to become persistent, becomes necessary. RF for the nerve roots might be a viable option for pain caused by pleural metastasis in cancer survivors.

Presumed first episode of nonconvulsive status epilepticus as the cause of postoperative disorder of consciousness following the completion of general anesthesia: A case report.

Key Clinical Message: Disorder of consciousness can lead to irreversible sequelae without proper intervention. Consequently, early diagnosis and treatment are of paramount importance in patients with disorder of consciousness. Abstract: Disorder of consciousness (DOC) has various etiologies. Here, we report a case in which DOC following general anesthesia was suspected as being due to the first episode of nonconvulsive status epilepticus (NCSE). An elderly man in his 80s underwent uneventful tumor resection surgery under general anesthesia for extramammary Paget's disease. After the procedure, he regained consciousness following anesthesia discontinuation and was extubated. Soon after extubation, however, although his respiratory status remained stable, his level of consciousness deteriorated to a Glasgow Coma Scale (GCS) score of E1V1M1. Head computed tomography and magnetic resonance imaging scans indicated no abnormal findings. Subsequently, involuntary movements were noted in his left upper limb. Suspecting an epilepsy episode, diazepam was administered, leading to an improvement in the level of consciousness (GCS: E4V5M6). Based on the improvement in consciousness after diazepam administration, we strongly suspected NCSE.

Two Cases of Splanchnic Nerve Block With Epidural Anesthesia in Patients Unable to Maintain Prone Position Due to Pancreatic Pain.

Splanchnic nerve block is considered to be effective for abdominal visceral pain, and is performed for the purpose of controlling abdominal pain and back pain caused by upper abdominal cancer. The patients in this case report were candidates for splanchnic nerve block owing to cancer-associated pain. However, because they could not assume the prone position that is required for the block owing to their pain, combined epidural anesthesia was used, resulting in successful implementation of the splanchnic nerve block. Patients who are candidates for splanchnic nerve block often have advanced cancer, and it is hence often difficult to secure and maintain the position required for the procedure owing to their severe pain. The two patients presented here suggest the possibility that epidural anesthesia might be useful as an adjunct in such cases.

Anesthesia using remimazolam during coronary artery bypass surgery in a patient with decreased left ventricular function.

Key Clinical Message: Remimazolam is a new benzodiazepine sedative and has the characteristic of causing minimal effects on circulation. This case indicates that it can be considered as an option for anesthesia management of patients with decreased cardiac function. Abstract: Some patients who undergo cardiac surgery have reduced cardiac function, which can often make anesthesia management difficult owing to severe hypotension at the time of anesthesia induction. Therefore, it is important to select drugs that cause minimal circulatory depression. On the other hand, in 2020, the use of remimazolam, a short-acting benzodiazepine sedative, was approved in Japan, and reports of its use in various patients have been increasing. This drug has the characteristic of causing minimal effects on circulation. We here report the safe use of remimazolam in the anesthesia management of a patient with decreased cardiac function who was diagnosed as having angina pectoris. The patient was a 73-year-old man scheduled for coronary artery bypass graft (CABG) surgery. Remimazolam was used for sedation purposes during anesthesia induction. During surgery, there were no significant hemodynamic changes and the patient remained in stable cardiovascular condition. Our present case indicates that remimazolam can be considered as an option for anesthesia management in CABG for patients with decreased cardiac function.

A case of phantom pain and stump pain that was effectively controlled by ultrasound-guided ulnar and median peripheral nerve blocks.

Phantom limb pain and stump pain are often intractable, and their incidences are relatively high. We report a case of a patient with phantom limb and stump pain of the finger, who was successfully treated by peripheral nerve blocks. The patient was a male truck driver in his fifties, who had his left annular finger amputated in an accident 2 years previously. Owing to poor pain control at the stump of his finger, he was referred to our department. The initial examination revealed pain about numerical rating scale (NRS) 6/10 in the left annular finger transection as well as allodynia. Although some pain relief had been observed with postoperative medication, he still had persistent resting pain of about NRS 4/10. Therefore, blocks of the ulnar nerve and median nerve were performed. After the blocks were performed, the pain improved to NRS 1 to 2/10, and pain upon movement also almost disappeared. Peripheral nerve blocks can be a useful treatment modality for phantom limb pain and stump pain in the fingers, as in this case.

Evaluation of total intravenous anesthesia with remimazolam in general anesthesia for pulmonary endarterectomy of chronic thromboembolic pulmonary hypertension: a case report.

BACKGROUND: Pulmonary endarterectomy (PEA) is a treatment modality for chronic thromboembolic pulmonary hypertension (CTEPH). PEA requires anesthesia management to prevent an increase in pulmonary vascular resistance (PVR) and circulatory failure. Therefore, it is necessary to select an anesthetic agent that can achieve these goals as much as possible. On the other hand, remimazolam, a short-acting sedative, was launched in Japan in 2020, and its use in various cases has been increasingly reported. This report demonstrates that remimazolam can be used safely in the anesthetic management of PEA. CASE PRESENTATION: A 57-year-old man was scheduled to undergo PEA for CTEPH. Remimazolam was used for sedation from induction of anesthesia. Hemodynamics were stable during surgery without circulatory failure. Anesthesia was managed intraoperatively without any particular increase in PVR. DISCUSSION: Anesthesia was successfully managed without any complications. This case suggests that remimazolam is one of the options for anesthetic management in PEA.

Transfusion-related acute lung injury under general anesthesia successfully treated with extracorporeal membrane oxygenation: A case report.

Transfusion-related acute lung injury (TRALI) is a serious complication of blood transfusion and can also develop severe hypoxemia. In TRALI cases with difficult blood oxygenation on mechanical ventilation support, temporary veno-venous extracorporeal membrane oxygenation support appears to maintain oxygen levels.

Comparative Evaluation of Endotoxin Activity Level and Various Biomarkers for Infection and Outcome of ICU-Admitted Patients.

Here, we concurrently measured the endotoxin activity (EA) level and levels of multiple biomarkers in patient blood obtained within 24 h after being admitted into the intensive care unit (ICU) and analyzed whether there were links between these markers and their associations with patient conditions and outcomes. The EA levels highly correlated with disease severity and patient survival, and showed a significant positive association with levels of lactate, procalcitonin, presepsin, and interleukin-6. Notably, the EA level was the marker that most highly correlated with the results of blood culture, and the presepsin level was the marker most highly correlated with the survival outcome at 28 days. Thus, the optimal biomarker should be selected based on whether it will be used to discriminate the presence of an infection or to predict survival.

[A Case of Mitral Valvular Re-repair in a Patient with Hemolytic Anemia after Mitral Valvular Repair].

A 54-year-old woman was admitted for mitral valvular repair. After folding plasty to A3, a 30 mm Cosgrove-Edwards ring was placed. There was no mitral regurgitation jet observed by transesophageal echocardiography (TEE) during the operation. However, high blood pressure was monitored and treated in the intensive care unit, hemolytic anemia developed, and the serum lactate dehydrogenase level was elevated. Two weeks after the operation, serum lactate dehydrogenase was again elevated. TEE showed mild mitral regurgitation and the regurgitation jet colliding with the annuloplasty ring. Multiple transfusions of red blood cells were required. Repeat surgery was therefore undertaken. Lam and associates previously studying patients on hemolysis after mitral valvular repair noted high grade mitral regurgitation jets fragmented or accelerated. In the present case, mitral regurgitation was mild, but the high velocity and manner of regurgitation (collision with the annuloplasty ring) could cause hemolytic anemia. In the present case, high blood pressure might have caused chordae rupture. Furthermore, a flexible ring, such as the Cosgrove-Edwards ring, is likely to cause hemolytic anemia. As contributing factors to hemolysis after mitral valvular repair, perioperative blood pressure management and type of ring are significant.

[Perioperative management of off-pump CABG for a 93-year-old man].

In recent years, the aging population has been growing, and the operative techniques and anesthetic methods have advanced. With these developments and medical support, the number of operations on very elderly patients has been increasing. We report the perioperative management of off-pump CABG for a 93-year-old man. When the heart was displaced during the operation, hypotension was induced and a marked reduction of his bispectral index (BIS) to "1" appeared. During the perioperative period, the patient developed delirium that was difficult to manage, but he was discharged from the hospital without any complications on POD 21. As part of the perioperative management, intraoperative cerebral circulatory management with attention to cerebral perfusion and prevention of postoperative delirium is crucial.

Simultaneous measurement of cytosolic and mitochondrial Ca(2+) during ischemia in mice whole-brain slice preparation and its application to drug evaluation.

We developed a conventional imaging method to measure Ca(2+) concentration in cytosol (using FuraRed as an indicator) and mitochondria (using Rhod-2 as an indicator), simultaneously, by alternative excitation with specific wave length. After confirming the availability of the method in Hela cells, we applied it to mouse whole-brain slice -preparation, which was exposed to oxygen- and glucose-deprived artificial cerebrospinal fluid (ischemic ACSF) for 12 min. The fluorescence (>570 nm) at the cerebral cortex and hippocampus due to FuraRed (excited by 480 ± 10 nm) decreased (indicating the increase in cytosolic Ca(2+)-concentration), while the fluorescence due to Rhod-2 (excited by 560 ± 10 nm) increased (indicating the increase in mitochondrial Ca(2+) concentration) during exposure to ischemic conditions. We found the characteristic protective effects of cyclosporine A (10(-6) M), a known blocker for mitochondrial permeability transition, and SEA0400 (10(-6) M), a blocker for Na(+)/Ca(2+) exchanger, on the abnormal Ca(2+) increase in cytosol. We confirmed that the present method will be useful for future pathological and pharmacological studies on ischemia-induced brain damage.

[Anesthesia management during coronary artery aneurysmectomy and tricuspid valvulectomy].

A 54-year-old man with infective tricuspid endocarditis and an infective right coronary artery aneurysm was scheduled for simultaneous coronary artery aneurysmectomy and tricuspid valvulectomy. However, the tricuspid valve replacement and annuloplasty procedures could not be performed because vegetation was noted on all his tricuspid leaflets. Moreover, the infective right coronary artery aneurysm was located proximal to the annulus of the tricuspid valve. Complications of tricuspid valvulectomy include tricuspid regurgitation, right ventricular capacity load and right ventricular pressure load. In the present case, after the patient was weaned from cardiopulmonary bypass (CPB), transesophageal echocardiography (TEE) revealed severe tricuspid regurgitation and shifting of the interventricular septum toward the left ventricle at the telediastolic stage. We managed this condition on the basis of the TEE findings with fluid therapy and a nitroglycerin vasoactive agonist, and adjusted the ventilator setting to reduce pulmonary vascular resistance. In the present case of infective tricuspid endocarditis with infective right coronary artery aneurysm, the selection of the appropriate surgical method was important. Moreover, respiratory management which did not increase pulmonary vascular resistance and adequate fluid management based on TEE findings after weaning from CPB were equally important during anesthesia for tricuspid valvulectomy.