General anesthesia with remimazolam for emergency cesarean section in a patient with acute infective endocarditis: a case report.

BACKGROUND: The anesthetic management of pregnant women with acute heart failure remains challenging with regard to maintaining the hemodynamic status of the mother and baby. The likelihood of decreased blood pressure is lower with remimazolam than with propofol. However, there is no report of general anesthesia with remimazolam for cesarean section. CASE PRESENTATION: The patient was a 34-year-old pregnant woman who was diagnosed with acute heart failure associated with infective endocarditis. We performed cesarean section under general anesthesia using remimazolam, with percutaneous cardiopulmonary support on standby. The mother's mean blood pressure was maintained above 65 mmHg during the surgery, without catecholamines or vasopressors. The infant's Apgar scores were 4 at 1 min and 7 at 5 min. CONCLUSION: Cesarean section was successfully performed under general anesthesia with remimazolam in a pregnant patient with acute heart failure. Further studies are needed to clarify the association between remimazolam and neonatal hypotension.

The dose-response relationships of the direct scavenging activity of amide-based local anesthetics against multiple free radicals.

This study aimed to illustrate the dose-response relationships of the direct scavenging activity of amide-based local anesthetics against multiple free radicals in vitro. We have demonstrated that amide-type local anesthetics selectively and directly scavenge some free radicals. Three kinds of free radicals were eliminated by all the four local anesthetics examined. Mepivacaine, lidocaine, bupivacaine, and dibucaine scavenged hydroxyl radicals in dose-dependent manners. Ascorbyl free radicals were also scavenged in dose-dependent manners, and lastly singlet oxygen was scavenged in dose-dependent manners. Three other free radicals were not scavenged by all of the four local anesthetics; tert-butoxyl radical was scavenged by all the anesthetics examined but dibucaine, nitric oxide by mepivacaine but not by the other three, and tyrosyl radical by mepivacaine and lidocaine but not by the other two. Some free radicals (superoxide anion, tert-butyl peroxyl radical, DPPH) were not scavenged by any of the four local anesthetics. The local anesthetics were also shown to inhibit lipid peroxidation by TBARS assay. These results suggest that local anesthetics have antioxidant properties through their free radical scavenging activities.

Real-time monitoring of vitamin C levels in trauma patients by electron-spin resonance spectrometry.

BACKGROUND: In critically ill patients, healthy vitamin C levels are important to avoid an imbalance in reactive oxygen species. To achieve this, oxidative stress levels in emergency patients need to be accurately measured in real-time. However, normally, reactive oxygen/nitrogen species are short-lived, rendering measurement difficult; moreover, measurement of relatively stable antioxidants and other oxidative stress markers in real-time is challenging. Therefore, we used electron-spin resonance spectrometry (ESR) to assess vitamin C levels, clarify their relationship with patients' severity, and establish more effective vitamin C therapy in critically ill patients. METHODS: We studied 103 severely ill emergency patients and 15 healthy volunteers. Vitamin C radical (VCR/dimethyl sulfoxide [DMSO]) values were analyzed in arterial blood samples by ESR at admission and once daily thereafter during the acute recovery phase. Severity scores were calculated. The relationship between these scores and VCR/DMSO values and chronological changes in VCR/DMSO values were analyzed. RESULTS: Serum VCR/DMSO values were significantly lower in critically ill patients than in healthy volunteers (0.264 ± 0.014 vs. 0.935 ± 0.052, p < 0.05), particularly in the severe trauma group and the cardiopulmonary arrest/post-cardiac arrest syndrome group. VCR/DMSO values and various severity scores did not correlate at admission; however, they correlated with SOFA scores from days 2-6. VCR/DMSO values remained low from the first measurement day through Day 6 of illness. CONCLUSIONS: Vitamin C levels were low at admission, remained low with conventional nutritional support, and did not correlate with the initial patient's severity; however, they correlated with patients' severity after admission. Some patients had normal vitamin C levels. Therefore, vitamin C levels should be measured in real-time and supplemented if they are below normal levels. TRIAL REGISTRATION: Retrospectively registered.

Sonographic diagnosis and evaluation in patients with superficial radial arteries.

BACKGROUND: The superficial radial artery (SRA) is a rare congenital anomaly in the forearm. However, it can be detected incidentally via trauma, intraoperative findings, angiography, or ultrasonography. In addition, intra-arterial infusion of intravenous medications and difficulties in radial artery catheterization may occur in cases of the SRA. METHODS: Between December 2016 and July 2020, anomalous branches of radial arteries were found incidentally in nine patients at the preoperative visit and identified during ultrasound-guided radial artery puncture in 21 patients when radial artery catheterization using the palpation method proved difficult. Ultrasound examinations were performed for diagnosis and evaluation of these 30 patients. RESULTS: All anomalous branches of the radial artery were SRAs; 11 (37%), 13 (43%), 6 (20%) were present on the right side, on the left side, and bilaterally, respectively. All SRAs ran close to the cephalic vein. The vascular diameters of the radial arteries were the smallest in the radial artery distal to the SRA bifurcation (followed by in the SRA) and the largest in the radial artery proximal to the bifurcation (p < .001). In two cases, color Doppler study revealed that both the blood flow and color Doppler signal of the SRA disappeared with compression of the radial artery proximal to the SRA bifurcation. CONCLUSIONS: Because the SRA runs very close to the cephalic vein, a tourniquet applied to the arm may easily lead to intravenous catheter misplacement into the SRA. In addition, the small radial artery distal to the SRA bifurcation causes difficulty in radial artery catheterization. Furthermore, SRA cases may have falsely normal Allen's test results. Therefore, the authors recommend that the SRA must be identified before vascular puncture for safe vascular catheterization in the forearm.

Application and Efficacy of Vitamin E-Bonded Polysulfone Membrane in Acute Blood Purification Therapy.

INTRODUCTION: Acute blood purification therapy (BPT) has been evaluated in the context of intensive care for serious conditions related to systemic inflammation, but its mechanism and efficacy are not fully understood. OBJECTIVE: This study examined the feasibility of using vitamin E-bonded polysulfone membranes (VEPS) for BPT in a LPS-induced rat model of systemic inflammation. METHODS: To evaluate the efficacy of BPT with a VEPS membrane, polysulfone (PS) membranes conventionally used in intensive care were bonded with the antioxidant vitamin E and used in a rat model of lipopolysaccharide (LPS)-induced systemic inflammation. BPT using a PS membrane (PS group) or a VEPS membrane (VEPS group) was performed 6 h after administration of LPS. Extracorporeal circulation was established in normal rats as a control (sham group). Survival rates, histology of lung specimens, and levels of myeloperoxidase (MPO) and high mobility group box-1 (HMGB-1) were examined in each group. RESULTS: Survival rates at 24 h after LPS administration were 100% in the VEPS group and 50% in the PS group. Pulmonary architecture was largely maintained and the level of infiltration of inflammatory cells remained moderate in the VEPS group. Levels of active MPO before and after BPT were significantly higher in the PS and VEPS groups than in the sham group, with no significant differences between the PS and VEPS groups. HMGB-1 levels were significantly elevated after BPT in the PS group. CONCLUSIONS: This study demonstrated that use of the VEPS membrane for BPT increased survival rate and reduced lung injury in a rat model of systemic inflammatory response syndrome (SIRS), suggesting the possible use of VEPS membranes in the treatment of serious conditions related to systemic inflammation.

Dose-dependent scavenging activity of the ultra-short-acting ß1-blocker landiolol against specific free radicals.

Landiolol, a highly cardioselective ultra-short-acting ß1-blocker, prevents perioperative atrial fibrillation associated with systemic inflammation and oxidative stress. We evaluated the direct scavenging activity of landiolol against multiple free radical species. Nine free radical species (hydroxyl, superoxide anion, ascorbyl, tert-butyl peroxyl, tert-butoxyl, singlet oxygen, 2,2-diphenyl-1-picrylhydrazyl, nitric oxide, and tyrosyl radicals) were directly quantified using an X-band ESR spectrometer with the spin-trapping method. IC50 and reaction rate constants were estimated from the dose-response curve for each free radical. Landiolol scavenged six of the free radical species examined: hydroxyl radical (IC50 = 0.76 mM, k landiolol = 1.4 × 10|10 M|-1 s|-1, p<0.001), superoxide anion (58 mM, 2.1 M|-1 s|-1, p = 0.044), tert-butoxyl radical (4.3 mM, k landiolol/k CYPMPO = 0.77, p<0.001), ascorbyl free radical (0.31 mM, p<0.001), singlet oxygen (0.69 mM, k landiolol/k 4-OH |TEMP = 2.9, p<0.001), and nitric oxide (15 mM, 1.7 × 10 M|-1 s|-1, p<0.001). This study is the first to report that landiolol dose-dependently scavenges multiple free radical species with different reaction rate constants. These results indicate the potential clinical application of landiolol as an antioxidative and anti-inflammatory agent in addition to its present clinical use as an anti-arrhythmic agent.

Comparison of three obturator nerve block techniques for injectate spread into the obturator canal: a randomized controlled trial.

PURPOSE: The obturator nerve branches into the obturator canal; therefore, local anesthetic spread into the obturator canal predicts the success of the obturator nerve block (ONB). We compared three ONB techniques for the spread of local anesthetic mixed with contrast medium into the obturator canal. METHODS: We performed the ONB using the classical pubic approach (PA), inguinal approach (IA), or ultrasound-guided methodologic approach (UMA) in 143 patients undergoing transurethral resection of bladder tumors. The obturator nerve course and branching patterns of the UMA group were examined using ultrasound imaging. After injecting a local anesthetic mixed with a contrast medium, we evaluated its spread into the obturator canal using fluoroscopic imaging. P < 0.05 indicated statistical significance. RESULTS: Success rate of obturator canal enhancement was the greatest in the UMA group (84%; P < 0.001); the PA (42.6%; 20/47 patients) and IA (47.8%; 22/46 patients) groups did not differ significantly (P = 1.000). Both branches of the obturator nerve passed above the superior margin of the external obturator muscle (EOM), and the obturator canal was enhanced in 13 of 50 (26%) patients in the UMA group. The posterior branch of the obturator nerve passed between the superior and main fasciculi of the EOM in 37 of 50 patients (74%) in the UMA group; the obturator canal was enhanced in 29 of these 37 patients (78%). CONCLUSION: Local anesthetic spread into the obturator canal using the UMA was superior to that using the PA and IA. Both branches of the obturator nerve could be blocked using the UMA.

High-Dose Vitamin C Preadministration Reduces Vancomycin-Associated Nephrotoxicity in Mice.

Vancomycin is recommended for treating severe infections caused by Gram-positive cocci, including methicillin-resistant Staphylococcus aureus. However, renal damage often occurs as a side effect because vancomycin is mainly excreted via the kidneys. The mechanism of vancomycin-associated nephrotoxicity is thought to involve the elevation of oxidative stress in the kidneys. Vitamin C (VC) has strong antioxidant properties; therefore, we evaluated the effect of high-dose VC preadministration on vancomycin-associated nephrotoxicity. Vancomycin was intraperitoneally injected into mice once daily for 7 d. Additionally, high-dose VC was intraperitoneally injected into mice at 30 min before vancomycin administration for 7 d. The plasma creatinine and urea nitrogen levels were increased by vancomycin treatment; however, high-dose VC preadministration suppressed the increase in these levels. Histological examination also revealed that high-dose VC preadministration reduced the characteristics of vancomycin-associated nephrotoxicity, such as dilated renal tubules with casts, the dilation of renal proximal tubules, and tubular epithelial desquamation. Furthermore, high-dose VC preadministration reduced the appearance of apoptotic cells presumably derived from the epithelial cells in the dilated proximal tubules. Thus, intraperitoneally injected high-dose VC preadministration reduced vancomycin-associated nephrotoxicity in mice. These novel findings may indicate that vancomycin-associated nephrotoxicity in humans may be reduced by high-dose VC preadministration.

Observation of Granulocyte Adsorption in Adacolumn Cellulose Acetate Beads after Granulocytapheresis.

Adacolumn is a therapeutic mode for ulcerative colitis that achieves therapeutic efficacy through the adhesion of leukocytes to cellulose acetate beads. We used scanning electron microscopy and observed leukocyte adsorption on Adacolumn beads after granulocytapheresis/granulocyte and monocyte adsorption apheresis. We then compared results between two patients with a low and high C-reactive protein (CRP) levels to determine whether adhesion is affected by a difference in leukocyte activity depending on the level of inflammation. We found that the surface layers of the beads from both patients were covered by a clay-like layer, and spherical granulocytes were adsorbed here and there on top of it. In cross-section the adsorbed granulocytes were visible in the clay-like layer and the surface layer alike. The clay-like layer had a maximum thickness of approximately 12 µm in the low CRP patient and approximately 50 µm in the high CRP patient, so in the high CRP patient the clay-like adsorption layer was thicker. Taken together, adsorption onto beads is considered to involve an immunological mechanism. Our findings suggest that granulocytes contact and adhere to each other at the surface layer after adsorption, and that granulocyte-granulocyte adhesion is enhanced by a higher inflammatory response.

Direct free radical scavenging effects of water-soluble HMG-CoA reductase inhibitors.

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, statins, are widely used for preventing cardiovascular and cerebrovascular diseases by controlling blood cholesterol level. Additionally, previous studies revealed the scavenging effects of statins on free radicals. We assessed direct scavenging activities of two water-soluble statins, fluvastatin and pravastatin, on multiple free radicals using electron spin resonance spectrometry with spin trapping method. We estimated reaction rate constants (k fv for fluvastatin, and k pv for pravastatin). Superoxide anion was scavenged by fluvastatin and pravastatin with k fv and k pv of 4.82 M-1s-1 and 49.0 M-1s-1, respectively. Scavenging effects of fluvastatin and pravastatin on hydroxyl radical were comparable; both k fv and k pv were >109 M-1s-1. Fluvastatin also eliminated tert-butyl peroxyl radical with relative k fv of 2.63 to that of CYPMPO, whereas pravastatin did not affect tert-butyl peroxyl radical. Nitric oxide was scavenged by fluvastatin and pravastatin with k fv and k pv of 68.6 M-1s-1 and 701 M-1s-1, respectively. Both fluvastatin and pravastatin had scavenging effects on superoxide anion, hydroxyl radical and nitric oxide radical. On the other hand, tert-butyl peroxyl radical was scavenged only by fluvastatin, suggesting that fluvastatin might have more potential effect than pravastatin to prevent atherosclerosis and ischemia/reperfusion injury via inhibiting oxidation of lipids.

Ultrasound-guided central venous tip confirmation via right external jugular vein using a right supraclavicular fossa view.

INTRODUCTION:: Ultrasound-guided central venous catheter tip confirmation has a potential to precisely locate the central venous catheter, preventing its misplacement, using real-time guidance. This observational study sought to determine the accuracy of central venous catheter tip positioning via the external jugular vein via a supraclavicular fossa view under ultrasound guidance. METHODS:: In total, 77 patients scheduled for central venous catheter insertion via the right external jugular vein were enrolled. The depth of central venous catheter insertion was determined by advancing the tip of the guidewire to the junction of the superior vena cava and right pulmonary artery, using a right supraclavicular fossa view ultrasound method. We determined the reference insertion depth to the carina using a postoperative chest x-ray photograph method. We then compared insertion depths obtained by the ultrasound and x-ray photograph methods and body-height formula. RESULTS:: In total, 62 patients were able to advance the guidewire and underwent ultrasound-guided central venous catheter insertion. In four patients, we corrected for misplaced guidewires. According to Bland-Altman plots, the insertion depth was 0.88 cm shorter for the ultrasound method (95% limits of agreement, -1.66 to 3.41 cm) and 0.90 cm shorter for the formulaic method (95% limits of agreement, -2.77 to 4.56 cm), compared with the x-ray photograph method. The x-ray photograph method had significantly positive correlations with the ultrasound (r = 0.73) and formulaic methods (r = 0.27). CONCLUSION:: A right supraclavicular fossa view improves the accuracy of central venous catheter tip positioning and prevents central venous catheter misplacement via the right external jugular vein.

Lateral deviation of four types of epidural catheters from the lumbar epidural space into the intervertebral foramen.

BACKGROUND: During epidural anesthesia, the catheter tip occasionally deviates from the epidural space into the intervertebral foramen, resulting in inadequate anesthesia. METHODS: During postoperative plain radiography, iohexol was injected via the epidural catheter to determine its position and to observe the spread of the material. After exclusion of seven patients with catheters that migrated into the subcutaneous area and 25 patients with no evidence of the contrast medium, 415 patients were evaluated. We retrospectively compared patients to determine whether the incidence of deviation into the intervertebral foramen differed between four types of epidural catheters. We also investigated the load applied to the catheter tip using a Shimadzu Autograph AG-X-500 N-111 universal testing machine. RESULTS: Deviation of the epidural catheter into the intervertebral foramen was observed in eight and 33 patients in the Hakko and Perifix Soft tip catheter groups, respectively. The incidence of deviation was higher in the Perifix Soft tip catheter group, and lower in the FlexTip Plus and Perifix FX catheter groups. A rapid increase was observed in the force exerted on the tips of the Hakko and Perifix Soft tip catheters, while the force transmitted to the tips of the FlexTip Plus and Perifix FX catheters gradually increased and then reached a plateau at a low level. CONCLUSIONS: The incidence of deviation was significantly lower with spiral-type catheters than with other types of catheters. This might be attributable to the gradual transmission of a lower level of force to the tip in spiral-type catheters.

Performance comparison of a new automated cuff pressure controller with currently available devices in both basic research and clinical settings.

BACKGROUND: The management of tracheal tube cuff pressure in patients receiving mechanical ventilation is important for the prevention of ventilator-associated pneumonia. Currently, cuff pressure is intermittently monitored with a pressure gauge and adjusted when necessary in a routine practice. However, this method results in wide variations in pressure, and adequate management is difficult due to the spontaneous release of air from the cuff, which reduces cuff pressure. In order to continuously maintain a uniform cuff pressure, we developed a new automated cuff pressure controller and compared its properties with existing devices. METHODS: The effectiveness of the new device was assessed with a model trachea/lung and tracheal tube by measuring cuff pressure while on mechanical ventilation. An electrically powered automatic cuff controller or manual cuff pressure control was used for comparison purposes. The effectiveness of the new device was also examined in patients receiving mechanical ventilation by continuously measuring cuff pressure for a 24-h period. RESULTS: Cuff pressure was uniformly maintained with the new device. Moreover, in the clinical setting, variation in pressure from the set pressure was minimal with both the new device and existing device, relative to the intermittent monitoring method. This suggests that, as with the existing device, uniform cuff pressure management is possible with the new device. CONCLUSIONS: Our results demonstrate the ability of the new cuff pressure controller to manage cuff pressure without the need of a power source, highlighting its potential utility in clinical settings.

New evaluation of fetal oxidative stress: measurement of the umbilical cord blood dimethyl sulfate-induced ascorbyl-free radical by an electron spin resonance method.

OBJECTIVE: The aim is to evaluate intrapartum fetal oxidative stress in real-time by umbilical cord blood dimethyl sulfate (DMSO)-induced ascorbyl-free radical (AFR) measured by an electron spin resonance (ESR) method. METHODS: Seventy-five mothers delivering at gestational age after 37 weeks were recruited. They were divided into three groups: spontaneous vaginal birth (n = 27), elective cesarean section (CS) (n = 34), and emergency CS due to non-reassuring fetal status (n = 14). Umbilical artery (UA) and venous (UV) cord blood gas analysis was performed. Serum levels of DMSO-induced AFR (AFR/DMSO) that reflect vitamin C concentrations were measured by ESR spectroscopy. RESULTS: Blood gas analysis showed no significant differences among the groups. UA-AFR/DMSO level of elective CS group was significantly lower compared with spontaneous delivery group (0.32 ± 0.12 versus 0.46 ± 0.14, p < 0.005). Emergency CS group showed significantly lower levels of UA-AFR/DMSO compared with elective CS group (0.25 ± 0.11 versus 0.32 ± 0.12, p < 0.005). UV-AFR/DMSO levels had no significant difference among the groups. CONCLUSIONS: It is suggested that fetal cord blood AFR/DMSO is a sensitive marker to assess fetal oxidative stress during delivery.

Uncoupling of peripheral and master clock gene rhythms by reversed feeding leads to an exacerbated inflammatory response after polymicrobial sepsis in mice.

Reversed feeding uncouples peripheral and master clock gene rhythms and leads to an increased risk of disease development. The aim of this study was to determine the effects of clock gene uncoupling on sepsis-induced inflammation using a mouse cecal ligation and puncture (CLP) model. C57BL/6N mice were entrained to a 12-h light-dark cycle (lights on at 7 AM). Mice were permitted ad libitum feeding either during the night (7 PM-7 AM) or the nonphysiological light phase (7 AM-7 PM) for a week before CLP. In daytime-fed mice, phase inversion of clock gene expression was observed in the liver, but not in the suprachiasmatic nucleus. Daytime-fed mice also had decreased body weight and food intake. Survival rate was significantly lower in daytime-fed mice (29%) compared with nighttime-fed mice (54%) 72 h after CLP (P = 0.03). Serum levels of interleukin 6 (IL-6), tumor necrosis factor α, high mobility group box 1, IL-1α, IL-9, eotaxin, and granulocyte colony-stimulating factor increased in daytime-fed mice compared with nighttime-fed mice after CLP. Baseline expression levels of sirtuin peroxisome 1 and proliferator-activated receptor γ coactivator 1α in the liver decreased in daytime-fed mice compared with nighttime-fed mice. Thus, daytime feeding induces clock gene uncoupling, which leads to decreased expression of longevity-related and energy metabolism proteins. Daytime feeding may also increase the levels of inflammatory cytokines, thereby increasing mortality in a mouse sepsis model. Our findings suggest that uncoupling of peripheral and master clock gene rhythms by reversed feeding exacerbates inflammatory responses.

Use of perioperative ureteral stent in abdominal aortic aneurysm with retroperitoneal fibrosis - A report of two cases -.

Retroperitoneal fibrosis is associated with fibroblast proliferation due to inflammatory changes in adipose/fibrous tissue. Given that aortic dilation in abdominal aortic aneurysm can cause compression of the ureter, abdominal aortic aneurysm complicated by retroperitoneal fibrosis is likely to result in urinary tract obstruction. Accordingly, close attention to changes in perioperative urine volume is warranted when operating on patients with abdominal aortic aneurysm complicated by retroperitoneal fibrosis. We have recently performed laparotomies on two cases of abdominal aortic aneurysm complicated by retroperitoneal fibrosis. In the first case, surgery was performed without the placement of a ureteral stent. The patient developed postrenal acute renal failure caused by postoperative urinary retention. In the second case, ureteral stent placement in advance enabled perioperative management without complications. The clinical course of these cases suggests that, in laparotomy with concomitant retroperitoneal fibrosis, preoperative ureteral stent placement can prevent postoperative complications in the renal and urinary systems.

New evaluation of fetal oxidative stress: measurement of the umbilical cord blood dimethyl sulfate-induced ascorbyl free radical by an electron spin resonance method.

OBJECTIVE: The aim is to evaluate intrapartum fetal oxidative stress in real-time by umbilical cord blood dimethyl sulfate (DMSO)-induced ascorbyl free radical (AFR) measured by an electron spin resonance (ESR) method. METHODS: 75 mothers delivering at gestational age after 37 weeks were recruited. They were divided into three groups: spontaneous vaginal birth (n = 27), elective cesarean section (CS) (n = 34), and emergency CS due to non-reassuring fetal status (n = 14). Umbilical artery (UA) and venous (UV) cord blood gas analysis was performed. Serum levels of DMSO-induced AFR (AFR/DMSO) that reflect vitamin C concentrations, was measured by ESR spectroscopy. RESULTS: Blood gas analysis showed no significant differences among the groups. UA-AFR/DMSO level of elective CS group was significantly lower compared with spontaneous delivery group (0.32 ± 0.12 vs. 0.46 ± 0.14, p < 0.005). Emergency CS group showed significantly lower levels of UA-AFR/DMSO compared with elective CS group (0.25 ± 0.11 vs. 0.32 ± 0.12, p < 0.005). UV-AFR/DMSO levels had no significant difference among the groups. CONCLUSIONS: It is suggested that fetal cord blood AFR/DMSO is a sensitive marker to assess fetal oxidative stress during delivery.