Abnormally low regional cerebral oxygen saturation after induction of anesthesia without neurological abnormality: A case report.

Measurement of regional cerebral oxygen saturation (rSO2) using near-infrared spectroscopy (NIRS) in cardiac surgery is known to be useful in reducing postoperative neurological complications. We here present a case of a 71-year-old man in whom severe decrease in unilateral rSO2 was observed after induction of general anesthesia for percutaneous mitral valve clipping, although no neurological abnormalities were found. NIRS does not always predict postoperative neurological complications.

Effect of averaging time and respiratory pause time on the measurement of acoustic respiration rate monitoring.

BACKGROUND: Acoustic respiration rate (RRa) monitoring is a method of continuously measuring respiratory rate using a signal from an acoustic transducer placed over the airway. The purpose of the present study is to examine how the averaging time and respiratory pause time settings of an RRa monitor affect the detection time of sudden respiratory rate changes. METHODS: A total of 40 healthy adult volunteers were included in the study. First, we measured the apnea detection time (apnea test) by dividing them into two groups (N = 20 each), one with a respiratory pause time setting of 20 s and the other with 40 s. Each group performed two apnea tests with an averaging time setting of 10 and 30 s. Next, we measured the tachypnea detection time (tachypnea test) for half of the subjects (N = 20) with two averaging time settings of 10 and 30 s. For each test, three measurements were taken, and the average of the three measurements was recorded. RESULTS: There was no significant difference in the apnea detection time between the averaging time set at 10 and 30 s regardless of whether the respiratory pause time was set at 20 or 40 s. However, the apnea detection time was significantly shorter with the respiratory pause time of 20 s than 40 s, regardless of whether the averaging time was set at 10 or 30 s (p < 0.001). The tachypnea detection time was shorter with the averaging time of 10 s than 30 s (p < 0.001). Furthermore, the apnea detection time and tachypnea detection time were much longer than the actual settings. CONCLUSIONS: The results of the current study show that in the measurement of RRa, the apnea detection time is more affected by the respiratory pause time setting than the averaging time setting; however, the tachypnea detection time is significantly affected by the averaging time setting.

Use of intraoperative transesophageal echocardiography and epiaortic ultrasound to diagnose false lumen enlargement of chronic aortic dissection.

In communicating aortic dissection, if only the entry or reentry is closed, residual blood flow may cause enlargement of the false lumen. In this case, surgeons were unable to occlude the entry with a stent graft due to the strong flexion of the bilateral common iliac arteries, so they closed only the reentry in the hope that blood flow from the reentry would be high. Unfortunately, due to the high blood flow from the entry, the false lumen was enlarged. But the use of transesophageal echocardiography and epiaortic ultrasound contributed to its diagnosis.

Failed spinal anesthesia due to accidental dural puncture: a case report.

BACKGROUND: We present a case of inadequate spinal anesthesia possibly due to cerebrospinal fluid (CSF) leakage into the epidural space caused by accidental dural puncture (ADP). CASE PRESENTATION: A 28-year-old woman with twin pregnancy underwent a cesarean section. She was scheduled to undergo combined spinal-epidural anesthesia (CSEA). Hyperbaric bupivacaine 9 mg with fentanyl 15 µg, with an additional bupivacaine 5 mg was administered from the L3/4 interspace for spinal anesthesia after repeated ADP at T12/L1; however, analgesia level was only up to T12. Insufficient analgesia level would be attributed to leakage of bupivacaine into the epidural space with the CSF via the injured dura. Planned surgery was performed under general anesthesia and completed uneventfully. CONCLUSION: In spinal anesthesia performed after ADP in pregnant women, the anesthesia level may not increase as expected if there is a large amount of CSF leakage.

Respiration and circulation affected by gas leakage into the abdominal cavity during endoscopic esophageal submucosal dissection after gastrostomy: a case report.

BACKGROUND: Pneumoperitoneum is a common complication of percutaneous endoscopic gastrostomy (PEG). We report a case of circulatory and respiratory depression due to pneumoperitoneum caused by PEG dislodgement during endoscopic submucosal dissection (ESD) surgery. CASE PRESENTATION: A 46-year-old man with PEG for dysphagia underwent ESD for esophageal cancer under general anesthesia. The patient developed a gradual increase in peak inspiratory pressure, followed by a decrease in peripheral oxygen saturation (SpO2) and blood pressure, as well as an increase in heart rate (HR) during endoscopic submucosal ESD for esophageal cancer. We suspected mediastinal emphysema due to esophageal perforation, but the surgery was successfully completed. Postoperative computed tomography (CT) revealed that the abdominal and gastric walls, which had been fixed by PEG, were detached, resulting in a large amount of intra-abdominal gas and mediastinal emphysema. CONCLUSIONS: ESD in patients with PEG should be performed carefully because of the possibility of intraoperative PEG dislodgement and pneumoperitoneum caused by insufflation gas leakage.

Transient maintenance of tracheal patency upon the insertion of a flexible bronchoscope in a patient with an anterior mediastinal mass: a case report.

BACKGROUND: Patients with an anterior mediastinal mass are at risk of perioperative respiratory collapse. CASE PRESENTATION: A 74-year-old woman with a large anterior mediastinal mass that led to partial tracheal collapse (shortest diameter, 1.3 mm) was scheduled for tracheobronchial balloon dilation and stent placement under general anesthesia. Although veno-venous extracorporeal membrane oxygenation (V-V ECMO) had been established, maximum flow was limited to 1.6 L/min, and general anesthesia induction was followed by hypoxia probably due to inadequate ventilation. A flexible bronchoscope was inserted through the tracheal lumen that was being compressed by the anterior mass; this not only increased tracheal patency but also enabled positive pressure ventilation and resulted in recovery from hypoxia. Scheduled procedures were successfully performed without complications. CONCLUSION: We describe a case wherein tracheal patency was transiently maintained by inserting a flexible bronchoscope in a patient with an anterior mediastinal mass.

Adjustment of oxygen reserve index (ORi™) to avoid excessive hyperoxia during general anesthesia.

The Oxygen Reserve Index (ORi™) is a non-invasive variable that reflects oxygenation continuously. The aims of this study were to examine the relationship between arterial partial pressure of oxygen (PaO2) and ORi during general anesthesia, and to investigate the usefulness of ORi as an indicator to avoid hyperoxia. Twenty adult patients who were scheduled for surgery under general anesthesia with arterial catheterization were enrolled. After induction of general anesthesia, inspired oxygen concentration (FiO2) was set to 0.33, and arterial blood gas analysis was performed. The PaO2 and ORi at the time of blood collection were recorded. After that, FiO2 was changed to achieve an ORi around 0.5, 0.2, and 0, followed by arterial blood gas analysis. The relationship between ORi and PaO2 was then investigated using the data obtained. Eighty datasets from the 20 patients were analyzed. When PaO2 was less than 240 mmHg (n = 69), linear regression analysis showed a relatively strong positive correlation (r2 = 0.706). The cut-off ORi value obtained from the receiver operating characteristic curve to detect PaO2 ≥ 150 mmHg was 0.21 (sensitivity 0.950, specificity 0.755). Four-quadrant plot analysis showed that the ORi trending of PaO2 was good (concordance rate was 100.0%). Hyperoxemia can be detected by observing ORi of patients under general anesthesia, and thus unnecessary administration of high concentration oxygen can possibly be avoided.

Dexmedetomidine administration in a patient with status epilepticus under color density spectral array monitoring.

BACKGROUND: Status epilepticus requires immediate treatment because treatment delay can cause permanent neurologic complications. Dexmedetomidine may be an option for the treatment of status epilepticus although its effect remains unclear with conflicting reports. CASE PRESENTATION: A 64-year-old woman with epilepsy with complex partial seizures underwent total knee arthroplasty. After emergence from general anesthesia, she developed status epilepticus and was transferred to the intensive care unit. Following initial treatment using benzodiazepines, phenytoin, and levetiracetam, dexmedetomidine (0.37 µg/kg loading in 10 min followed by 0.6 µg/kg/h) was administered and seizures terminated in 20 min. Color density spectral array using Root® with SedLine® (Masimo, Irvine, CA, USA) showed an increase in power in high frequency band of the electroencephalogram during the seizure attacks. CONCLUSION: We described a case of status epilepticus which was treated with dexmedetomidine and monitored using color density spectral array.

Correction to: Dexmedetomidine administration in a patient with status epilepticus under color density spectral array monitoring.

Following publication of the original article [1], the authors reported an error in Fig. 1b and c. A black bar and arrows were added.

Comparison of magnesium alloys and poly-l-lactide screws as degradable implants in a canine fracture model.

The aims of this study were to evaluate in vivo the biological responses to implants composed of biodegradable anodized WE43 (containing magnesium yttrium, rare earth elements and zirconium; Elektron SynerMag®) magnesium alloy, monolithic WE43 magnesium alloy and poly-l-lactic acid (PLLA), which are commonly used materials in clinic settings, and to evaluate the effectiveness of the materials as bone screws. The effectiveness of the magnesium alloy implants in osteosynthesis was evaluated using a bone fracture model involving the tibia of beagle dogs. For the monolithic WE43 implants, radiological, and histological evaluation revealed that bone trabeculae around the implanted monolithic WE43 decreased because of an inflammatory response. However, there was no damage due to hydrogen gas or inflammatory response in the bone tissue around the anodized WE43 implants. After 4 weeks, all the PLLA implants (n = 3) had broken but the WE43 implants had not (n = 6). These results suggest that the WE43 implants had sufficient strength to fix bone fractures at load-bearing sites in orthopedic and oral maxillofacial surgery. Therefore, these biodegradable magnesium alloys are good candidates for replacing biodegradable polymers. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 104B: 1282-1289, 2016.

Nurmi-type Culture Prepared using Culture Media without l-Cysteine Enhances Salmonella Exclusion in Hatched Layer Chicks.

To determine the influence of media composition on Salmonella exclusion of Nurmi-type cultures, two and four types of cultures in the first and second trial, respectively, were prepared from the cecal contents of conventional laying hens, and Salmonella exclusion was assessed in newly hatched chicks. In the first trial, modified Viande Levure (VL) broth or nutrient broth (NB) were used to prepare Nurmi-type cultures (N-VL and N-NB), which were administered to the newly hatched chicks. Twenty-four hours later, the chicks were challenged with Salmonella enterica Typhimurium EF85-9 (ST). ST recoveries (log10 colony forming units/g of cecal contents) from the N-VL-, N-NB-, and control-treated groups 5 days after the challenge were 7.6±0.6, 0.9±1.9, and 7.7±0.4, respectively. The results suggested the influence of l-cysteine (Cys) present in the VL broth. Thus, we determined the effect of Cys in the second trial. We prepared two other cultures using VL broth without Cys (N-VL-Cys) and NB with Cys (NNB-Cys). ST recoveries from the cecal contents of the N-VL-, N-VL-Cys-, and control-treated groups were 6.3±0.9, 2.1±2.5, and 9.2±0.8, respectively. ST was not recovered from the N-NB- and N-NB-Cys-treated groups. To identify bacteria with Salmonella exclusion activity, we isolated 41 bacterial strains from the ceca of N-NB-treated chicks without Salmonella challenge. Most isolates were identified as Enterococcus faecalis or E. mundtii based on 16S rRNA gene sequencing, and only four cultures excluded Salmonella. Therefore, VL broth containing Cys was not always required for preparing Nurmi-type cultures. The use of media prepared with Cys at the lowest possible concentration or without Cys would promote to enhance Salmonella exclusion from Nurmi-type cultures.

In situ expression of the mitochondrial ATPase6 gene in the developing tooth germ of the mouse lower first molar.

We previously performed cDNA subtraction between the mouse mandibles on embryonic day 10.5 (E10.5) in the pre-initiation stage of the odontogenesis and E12.0 in the late initiation stage to identify genes expressed at its beginning. Adenosine triphosphate synthase subunit a (Atpase6) is one of the highly expressed genes in the E12.0 mandible including tooth germs. In situ hybridization was conducted using the mouse mandibular first molar from E10.5 to E18.0 to determine the precise expression patterns of Atpase6 mRNA in the developing tooth germ. Atpase6 mRNA was strongly expressed in the presumptive dental epithelium and the underlying mesenchyme at E10.5, and in the thickened dental epithelium at E12.0 and E13.0. Strong in situ signals were observed in the epithelium at E14.0, and in the enamel organ excluded the area of the primary enamel knot at E15.0. Atpase6 was strongly expressed in the inner enamel epithelium, the adjacent stratum intermedium, and the outer enamel epithelium in the cervical loops from E16.0 to E18.0. In addition, strong Atpase6 signals were coincidently demonstrated in various developing cranio-facial organs. These results suggest that Atpase6 participates in the high energy-utilizing functions of the cells related to the initiation and the development of the tooth germ as well as those of the other cranio-facial organs.

Functional implication of nucleolin in the mouse first molar development.

We examined the functional implication of nucleolin in the mouse first molar development. Both the nucleolin mRNA and protein expressions were demonstrated in the odontogenic epithelial cells in the early stage and in the inner enamel epithelial layer in the late stage. The expression pattern of nucleolin corresponded to the proliferating cells in the tooth germ, thus showing that nucleolin could possibly be related to cell proliferation. No in situ signal of nucleolin was found in the primary enamel knot (PEK). Furthermore, nucleolin protein was demonstrated in the PEK by immunohistochemistry. The existence of nucleolin protein in the PEK may possibly be related to the apoptosis in the PEK cells. An inhibition assay using the hemagglutinating virus of Japan-liposome containing nucleolin antisense phosphorothioated oligonucleotide (AS S-ODN) in cultured mouse mandibles at embryonic day (E) 11.0 showed a marked growth inhibition of tooth germ. Moreover, no developmental arrest was found in the cultured tooth germ at E15.0 treated with nucleolin AS S-ODN. Real time PCR was performed to examine the mRNA expression of nucleolin-related genes, and a significant reduction in the midkine mRNA expression was thus observed in the mouse mandible after being treated with nucleolin AS S-ODN. This inhibition assay indicated that nucleolin could thus be involved in the early stage of tooth germ initiation and morphogenesis, possibly by regulating the midkine expression.