Anesthetic Management of a Surgical Patient with Chronic Renal Tubular Acidosis Complicated by Subclinical Hypothyroidism.

A 53-year-old man with chronic renal tubular acidosis and subclinical hypothyroidism underwent lower leg amputation surgery under general anesthesia. Perioperative acid-base management in such patients poses many difficulties because both pathophysiologies have the potential to complicate the interpretation of capnometry and arterial blood gas analysis data; inappropriate correction of chronic metabolic acidosis may lead to postoperative respiratory deterioration. We discuss the management of perioperative acidosis in order to achieve successful weaning from mechanical ventilation and promise a complete recovery from anesthesia.

Nonocclusive mesenteric ischemia following multiple wasp stings.

Massive wasp envenomation can cause not only severe immediate allergic reactions and anaphylaxis but also severe delayed toxin-mediated systemic reactions, including hemolysis, coagulopathy, rhabdomyolysis, acute renal failure, and hepatotoxicity. However, reports of the latter type of reactions are rare. The subject of this case report, a 66-year-old man, was stung more than 30 times during an attack by wasps. Although he initially complained of pain, he showed no signs of anaphylaxis during observation in an emergency department. Twenty hours after envenomation, he was admitted to the hospital because of vomiting, abdominal pain, and lower gastrointestinal bleeding. Mesenteric ischemia, rhabdomyolysis, acute renal failure, and hepatotoxicity were diagnosed as delayed toxin-mediated systemic reactions resulting from massive wasp envenomation. Contrast-enhanced computed tomography findings, which included no thrombi or emboli but did reveal the abrupt tapering of mesenteric arteries, strongly suggested that the ischemia was due to nonocclusive mesenteric ischemia. Immediately after diagnosis, an emergency laparotomy was performed. Nonocclusive mesenteric ischemia was finally diagnosed via a histologic examination of the resected small bowel. We present the first case report of nonocclusive mesenteric ischemia consequent to wasp stings.

Corticosteroid enhances heme oxygenase-1 production by circulating monocytes by up-regulating hemoglobin scavenger receptor and amplifying the receptor-mediated uptake of hemoglobin-haptoglobin complex.

This study examined the relationship between steroid treatment and CD163-mediated downstream pathways linked to inflammatory resolution. Twelve patients referred for congenital heart disease surgery were divided into two groups based on the severity of intravascular hemolysis during cardiopulmonary bypass surgery. Patients with severe intravascular hemolysis were administered haptoglobin during the procedure. Flow cytometry indicated a peak in monocyte CD163 expression on post-operative day 1 in both groups. Enhanced and prolonged heme oxygenase-1 (HO-1) mRNA expression levels were observed in patients who received haptoglobin. Binding of hemoglobin-haptoglobin complex (Hb/Hp) to CD163 resulted in significant induction of HO-1 by peripheral blood mononuclear cells after exposure to dexamethasone prior to culture. This effect was significantly inhibited by anti-CD163 antibody. Our results demonstrated up-regulation of CD163 expression on the monocyte surface by steroid treatment. Steroid treatment was suggested to facilitate CD163-mediated endocytosis of hemoglobin to monocytes/macrophages and thereby induce acceleration of HO-1 synthesis.