Inhalational Anesthesia Reduced Transient Neurological Events After Revascularization Surgery for Moyamoya Disease.

BACKGROUND AND OBJECTIVES: The choice between inhalational and total intravenous anesthesia (TIVA) in revascularization surgery for Moyamoya disease (MMD) remains a topic of debate. Anesthesia methods have changed with the advent of new anesthetics. This study investigated whether modern anesthesia methods affected the development of neurological symptoms after revascularization surgery for MMD. METHODS: This single-center retrospective study included 63 adult patients (82 hemispheres) with MMD treated with direct and indirect bypass surgeries at our hospital between 2013 and 2022. Patients were divided into inhalational anesthesia (IA) and TIVA groups based on the anesthesia maintenance method. Baseline patient characteristics; postoperative neurological symptoms, including hyperperfusion syndrome, cerebral infarction, and transient neurological events (TNEs); and cortical hyperintensity belt (CHB) sign scores (5-point scale from 0 to 4) on postoperative magnetic resonance imaging were compared between the two groups. The operation methods, anesthetics, and intraoperative hemodynamic and ventilatory parameters were compared between patients with and without TNEs. RESULTS: The IA and TIVA groups comprised 39 and 43 hemispheres, respectively. The frequency of postoperative hyperperfusion syndrome and cerebral infarction did not differ between the groups, but the number of TNEs in the IA group (5/39; 13%) was significantly lower than that in the TIVA group (16/43; 37%). Multivariate logistic regression analysis revealed that TNEs were associated with TIVA (odds ratio, 3.91; 95% CI, 1.24-12.35; P = .02). The median [IQR] postoperative CHB sign score in the IA group (2 [1-3]) was significantly lower than that in the TIVA group (4 [3-4]). CONCLUSION: The IA group had fewer postoperative TNEs and lower CHB sign scores than the TIVA group. Although further studies are needed, this study provides insights into the prevention of TNEs with IA and reconsideration of the optimal anesthesia for MMD.

Increased numbers of pre-operative circulating monocytes predict risk of developing cardiac surgery-associated acute kidney injury in conditions requiring cardio pulmonary bypass.

BACKGROUND: Evaluating patients' risk for acute kidney injury (AKI) is crucial for positive outcomes following cardiac surgery. Our aims were first to select candidate risk factors from pre- or intra-operative real-world parameters collected from routine medical care and then evaluate potential associations between those parameters and risk of onset of post-operative cardiac surgery-associated AKI (CSA-AKI). METHOD: We conducted two cohort studies in Japan. The first was a single-center prospective cohort study (n = 145) to assess potential association between 115 clinical parameters collected from routine medical care and CSA-AKI (≥ Stage1) risk in the population of patients undergoing cardiac surgery involving cardiopulmonary bypass (CPB). To select candidate risk factors, we employed random forest analysis and applied survival analyses to evaluate association strength. In a second retrospective cohort study, we targeted patients undergoing cardiac surgery with CPB (n = 619) and evaluated potential positive associations between CSA-AKI incidence and risk factors suggested by the first cohort study. RESULTS: Variable selection analysis revealed that parameters in clinical categories such as circulating inflammatory cells, CPB-related parameters, ventilation, or aging were potential CSA-AKI risk factors. Survival analyses revealed that increased counts of pre-operative circulating monocytes and neutrophils were associated with CSA-AKI incidence. Finally, in the second cohort study, we found that increased pre-operative circulating monocyte counts were associated with increased CSA-AKI incidence. CONCLUSIONS: Circulating monocyte counts in the pre-operative state are associated with increased risk of CSA-AKI development. This finding may be useful in stratifying patients for risk of developing CSA-AKI in routine clinical practice.

A role for the locus coeruleus in the analgesic efficacy of N-acetylaspartylglutamate peptidase (GCPII) inhibitors ZJ43 and 2-PMPA.

N-acetylaspartylglutamate (NAAG) is the third most prevalent and widely distributed neurotransmitter in the mammalian nervous system. NAAG activates a group II metabotropic glutamate receptor (mGluR3) and is inactivated by an extracellular enzyme, glutamate carboxypeptidase II (GCPII) in vivo. Inhibitors of this enzyme are analgesic in animal models of inflammatory, neuropathic and bone cancer pain. NAAG and GCPII are present in the locus coeruleus, a center for the descending noradrenergic inhibitory pain system. In the formalin footpad model, systemic treatment with GCPII inhibitors reduces both phases of the inflammatory pain response and increases release of spinal noradrenaline. This analgesic efficacy is blocked by systemic injection of a group II mGluR antagonist, by intrathecal (spinal) injection of an alpha 2 adrenergic receptor antagonist and by microinjection of an α-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptor antagonist directly into the contralateral locus coeruleus. Footpad inflammation increases release of glutamate in the contralateral locus coeruleus and systemic treatment with a GCPII inhibitor blocks this increase. Direct injection of GCPII inhibitors into the contralateral or ipsilateral locus coeruleus reduces both phases of the inflammatory pain response in a dose-dependent manner and the contralateral effect also is blocked by intrathecal injection of an alpha 2 adrenergic receptor antagonist. These data support the hypothesis that the analgesic efficacy of systemically administered GCPII inhibitors is mediated, at least in part, by the contralateral locus coeruleus via group II mGluR, AMPA and alpha 2 adrenergic receptors.

Failure of a "foolproof" pin-index medical pipeline system.

BACKGROUND: The pin-index medical gas pipeline system, which complies with Japan Industrial Standard (JIS), is considered to be "foolproof" and is widely used in Japan to avoid medical gas misconnections. CASE PRESENTATION: The wall-mounted gas outlet used in our hospital (NSV outlet, CENTRAL UNI, Co., Ltd., Tokyo, Japan) contains multiple sockets, which connect to hoses with gas-specific pins. Each socket is covered with a gas-specific plastic pin guide, which is considered to make the system foolproof; i.e., to prevent misconnections. However, while checking an anesthesia machine in accordance with the guidelines developed by the Japanese Society of Anesthesiologists, an anesthesiologist found that one of the gas-specific plastic pin guides covering the wall-mounted gas outlets had disappeared; and hence, the gas outlet system was no longer foolproof. A subsequent verification test performed by engineers of the system's manufacturer revealed that the plastic pin guides could be dislodged by applying 29.4 N of vertical force. CONCLUSIONS: It is important to check that gas outlet systems are functioning in a gas-specific manner when they are used for clinical purposes.

Development and validation of the Calculation of post-Operative Risk in Emergency Surgery (CORES) model.

PURPOSE: This study was undertaken to establish a model to predict the post-operative mortality for emergency surgeries. METHODS: A regression model was constructed to predict in-hospital mortality using data from a cohort of 479 cases of emergency surgery performed in a Japanese referral hospital. The discrimination power of the current model termed the Calculation of post-Operative Risk in Emergency Surgery (CORES), and Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were validated using the area under the receiver operating characteristic curve (AUC) in another cohort of 494 cases in the same hospital (validation subset). We further evaluated the accuracy of the CORES in a cohort of 1,471 cases in six hospitals (multicenter subset). RESULTS: CORES requires only five preoperative variables, while the P-POSSUM requires 20 variables. In the validation subset, the CORES model had a similar discrimination power as the P-POSSUM for detecting in-hospital mortality (AUC, 95 % CI for CORES: 0.86, 0.80-0.93; for P-POSSUM: 0.88, 0.82-0.93). The predicted mortality rates of the CORES model significantly correlated with the severity of the post-operative complications. The subsequent multicenter study also demonstrated that the CORES model exhibited a high AUC value (0.85: 0.81-0.89) and a significant correlation with the post-operative morbidity. CONCLUSIONS: This model for emergency surgery, the CORES, demonstrated a similar discriminatory power to the P-POSSUM in predicting post-operative mortality. However, the CORES model has a substantial advantage over the P-POSSUM in that it utilizes far fewer variables.