Leptomeningeal Metastases in a Patient with Castration-Resistant Prostate Cancer.

A 42-year-old man visited a community hospital with chief complaints of lumbago and dyschesia. Computed tomography (CT) showed multiple lung, lymph node, and bone metastases and the irregular enlarged prostate with urinary bladder invasion. Serum prostate-specific antigen (PSA) was 544.0 ng/mL. Histological evaluation showed adenocarcinoma with the Gleason score 5 + 4, and the clinical stage was T4N1M1c as an initial diagnosis. Although androgen deprivation therapy was performed immediately, he had castration-resistant PCa after 3 months. Therefore, he received 6 courses of docetaxel chemotherapy every 3 weeks. Serum PSA was decreased to 0.2 ng/mL, and multiple metastases and prostate size were obviously reduced based on CT. He underwent robot-assisted radical prostatectomy and radiation therapy for prostatic fossa and multiple metastases. Although serum PSA level remained low, CT showed multiple liver metastases after 3 years from surgery. He received the combination therapy of cisplatin and etoposide (PE) every 4 weeks. Liver metastases had complete response. However, he visited our hospital with complaint of vomiting and a right drooping eyelid after 6 weeks from withdrawal of PE therapy. T2-weighted magnetic resonance imaging revealed multiple leptomeningeal metastases (LM). He received RT for the brain and was administered amrubicin. However, he died of PCa after 6 weeks from the diagnosis of LM.

Higher plasma leptin and lower C-peptide levels are associated with depression: A cross-sectional study.

BACKGROUND: Depression is a seriously disabling public health problem with very high world-wide prevalence. This study examined cross-sectional association between depression and both inflammatory markers and laboratory data involved in metabolic disturbance among Japanese subjects. METHODS: This cross-sectional study is a secondly analysis for the data of the Iwaki Health Promotion Project 2014 (1167 subjects). Plasma inflammatory markers and laboratory metabolic data involved were used. Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess the prevalence and severity of depressive symptoms. Participants with CES-D scores ≥ 16 were assigned to the 'Depression' group (Group D). Differences between group Non-depression (ND) and D were estimated using χ2 test or Fisher's exact test for categorical variables and Student's t-test or Mann-Whitney test for continuous variables. Multivariate logistic regression analysis was also used to identify characteristics, co-morbidities, conditions and laboratory data associated with depression after adjusting for possible confounding factors. RESULTS: There were significant differences in sex, age, blood pressure, interleukin (IL)-6, fasting blood sugar (FBS), hemoglobin A1c (HbA1c), and cortisol level using univariate analysis between the two groups. However, multivariate logistic regression analysis indicated that lower age, lower C-peptide, and higher leptin were associated with the depression. CONCLUSION: This study showed that higher plasma leptin and lower C-peptide levels were significantly associated with depressive symptoms. No significant association was found between plasma inflammatory markers and depressive symptoms after adjusting for possible confounding factors.

Usefulness of dexmedetomidine to prevent emergence agitation in a patient with Krabbe disease: a case report.

BACKGROUND: We report the case of a child with Krabbe disease who underwent three repeated surgeries and anesthetic management, and we discuss the major concerns about Krabbe disease and the usefulness of a perioperative administration of dexmedetomidine to prevent emergence agitation and hypertension. The patient was scheduled to undergo bilateral orchiopexy, adenotonsillectomy, and knee flexor tendon lengthening under general anesthesia during a 2-year period. CASE PRESENTATION: Adenotonsillectomy was scheduled as the second operation when the patient was 4 years old. His height and body weight were 93 cm and 10.3 kg, respectively. Anesthesia was induced with 8% sevoflurane mixed with 6 L/min of O2 and maintained with N2O (3.5 L/min), O2 (1.5 L/min), and sevoflurane (1.5-2.0%). Upon completion of the right tonsillectomy, 1 h before the end of the surgery, a continuous infusion of dexmedetomidine (0.2 µg/kg/h) was started to prevent emergence agitation, irritability, resultant hypertension, and postoperative bleeding. Fentanyl (25 µg) was administered intravenously to reduce postoperative pain. The surgery was uneventful, and the patient's emergence from general anesthesia was prompt. He exhibited no symptoms of emergence agitation or irritability. During his stay in the intensive care unit, 0.2-0.7 µg/kg/h of dexmedetomidine and 6.25 µg/h of fentanyl were continuously administered. The patient was discharged to the ward the following morning without complications. CONCLUSIONS: The perioperative administration of dexmedetomidine was useful to prevent emergence agitation, hypertension, and resultant postoperative bleeding in a pediatric patient with Krabbe disease. Three repeated anesthetic management using inhalation anesthesia were completed uneventfully without muscle relaxants.

[Tension Pneumothorax Developing Hemothorax after Chest Tube Drainage].

A 61-year-old man visited a physician complaining of progressive chest pain and dyspnea. The chest radiography showed complete collapse of the right lung suggesting tension pneumothorax. The patient was transferred to our hospital. A small amount of the right pleural effusion was also seen in addition to pulmonary collapse on the chest radiography. Chest drainage was performed, and continuous air leakage was seen. At 2 hours later, air leakage was disappeared but the bloody effusion was noted. The chest radiography revealed massive effusion and the enhanced computed tomography showed active bleeding. The emergency surgery was conducted. The bleeding point was a ruptured vessel between the apical parietal pleura and the pulmonary bulla. Hemostasis and the resection of the bullae was performed. Careful observation after chest drainage is necessary to prepare unexpected hemothorax in case of tension pneumothorax with pleural effusion.

[Effects of Various Antidepressants on Hemodynamics during General Anesthesia].

BACKGROUND: It is known that serious refractory hypotension during anesthesia may develop in some patients treated with antidepressants. However the detail of this phenomenon remains unclear. METHODS: We performed a retrospective study based on written anesthesia records from April 2011 through September 2012 (n=5,578). We picked up patients who had received various types of antidepressants. We excluded cases in which neuraxial anesthesia had been performed, and preoperative general condi- tion or performed operation had affected hemodynam- ics greatly. 91 of 5,578 patients were included. All 91 patients received general anesthesia using propofol. We checked type of antidepressants taken and use of vasopressors during anesthesia. RESULTS: Type of antidepressants taken by 91 patients had no effect on the frequency of vasopressor administration. However, 7 of 91 patients showed treatment-resistant refractory hypotension by ephed- rine and phenylephrine. Catecholamines (noradrenaline, dobutamine) were effective. Frequency of refractory hypotension was significantly higher with serotonin and noradrenaline reuptake inhibitors (SNRI) or with two combined antidepressants. CONCLUSIONS: Type of antidepressants had no effect on frequency of vasopressor administration. Treat- ment-resistant refractory hypotension by ephedrine and phenylephrine was significantly higher with SNRI or two combined antidepressants. Sympathetic nerve activity may be influenced by interaction of anesthetics and antidepressants in some patients.

Impact of robot-assisted laparoscopic prostatectomy on the management of general anesthesia: efficacy of blood withdrawal during a steep Trendelenburg position.

INTRODUCTION: Robot-assisted laparoscopic prostatectomy (RALP) is being increasingly used. However, a steep Trendelenburg position and pneumoperitoneum during RALP has an impact on the respiratory, cardiovascular and cerebrovascular systems. To prevent complications, restrictive fluid management and blood withdrawal have been utilized in our hospital. We examined differences in the anesthetic management between RALP and radical retropubic prostatectomy (RRP), and the efficacy of blood withdrawal. METHODS: Medical records of patients who underwent radical prostatectomy in our hospital between January 2012 and October 2013 were retrospectively reviewed. Demographic data, intraoperative blood and fluid administration, perioperative complications and the length of hospital stay were compared among patients receiving RRP, and those receiving RALP with and without blood withdrawal (n = 78, 46 and 68, respectively). RESULTS: Patients receiving RALP with and without blood withdrawal received a smaller volume of crystalloid during surgery than those receiving RRP (mean ± SD, 5.8 ± 2.3 and 4.2 ± 1.6 vs 14.3 ± 4.1 ml/kg/h, p < 0.001). Median estimated blood loss was 885 g (80-2,800 g) for RRP and 50 g for RALP (3-950 g and 3-550 g, respectively), p < 0.001. None of the patients undergoing RALP received red blood cells, but three patients undergoing RRP did so. RALP with blood withdrawal reduced postoperative hospital stay by 45 % (6 vs 11 days). Four patients receiving RALP without blood withdrawal had delayed extubation due to severe laryngeal edema, which did not occur in any of the patients receiving RALP who had blood withdrawal. Renal function did not differ among the groups. CONCLUSIONS: RALP was associated with less blood loss, no allogeneic transfusion and shorter postoperative hospital stay. This study indicated that blood withdrawal could prevent severe laryngeal edema.

[Case of Rh (-) patient's right lobectomy of the liver with massive hemorrhage evading allogeneic blood transfusion by hemodilutional autologous blood transfusion].

A 44-year-old man (ASA-PS 1) underwent right lobectomy of the liver under total intravenous anesthesia with propofol, remifentanil, ketamine and rocuronium. In order to evade allogeneic blood transfusion, 1,200 g of the patient's blood was taken and hemodilution was induced for autologous blood transfusion (HAT) after the induction of anesthesia. As intraoperative blood loss amounted to about 4,000 g, Hb level decreased from 13.6 to 6.2 g x dl(-1). However, as intraoperative hemodynamics was relatively stable with crystalloidal and colloidal transfusion with no ischemic change on ECG and no metabolic acidosis, autologous blood transfusion was withheld. After returning the autologous blood, Hb increased to 9.8 g x dl(-1). Any postoperative complications related to the low Hb level were not recognized. HAT is a useful method to evade or at least decrease the amount of allogeneic blood transfusion by anesthesiologists.

[Case of urgent surgical cricothyrotomy in CICV situation during induction of anesthesia for hemostasis after tonsillectomy].

A 38-year-old man (BMI 31) underwent bilateral tonsillectomy for sleep apnea syndrome under general anesthesia without any airway difficulty. On the fifth post-operative day excessive bleeding occurred suddenly. Emergency tracheostomy was planned, not under local anesthesia but general anesthesia in the presence of otolaryngologists for urgent tracheostomy, since the patient could not lie in the supine position. Tracheal intubation was tried using rapid sequence technique. However, excessive bleeding in the oral cavity did not allow successful direct laryngoscopy, resulting in CICV situation. When CICV situation was con- firmed associated with SpO2 91%, surgical cricothyrotomy was started by otolaryngologists. SpO2 decreased to 13% associated with heart rate of 38 beats · min-1 immediately before restoration of ventilation and oxygenation. After hemostasis, he showed uneventful post-operative course. On the occasion of airway management for excessive laryngopharyngeal bleeding, emergency surgical crycothyrotomy should be performed immediately before the fall of oxygen tension, if rapid sequence tracheal intubation had failed.

[Rectus sheath block and transversus abdominis plane block for a patient with Lambert-Eaton myasthenic syndrome undergoing low anterior resection].

A 55-year-old male with Lambert-Eaton myasthenic syndrome underwent low anterior resection. Before anesthetic induction, his arterial blood gas analysis showed chronic hypercapnia (pH 7.404, Paco2 59 mmHg, BE 9.1). Anesthesia was induced with propofol, remifentanil and ketamine. Uneventful tracheal intubation was achieved after superior laryngeal nerve block without using muscle relaxants. Then ultrasound-guided bilateral rectus sheath block and transversus abdominis plane block were performed using 60 ml of 0.375% ropivacaine. Anesthesia was maintained with propofol, remifentanil monitoring bispectral index. Good surgical condition was maintained even without using muscle relaxants. Although only a small amount of morphine was required during the early postoperative days, his postoperative course was smooth and uneventful. The present case shows that ultrasound-guided rectus sheath block and transversus abdominis plane block are safe and useful for abdominal surgery in patients with neuromuscular disease.

Mild hypercapnia with hyperventilation attenuates recovery from anesthesia in elderly patients.

PURPOSE: Mild hypercapnia with hyperventilation has been reported to significantly decrease recovery time from inhaled anesthesia in young and middle-aged patients. However, its efficacy has not yet been clarified in elderly patients, although delayed emergence can deteriorate their quality of recovery. METHODS: We enrolled 30 elderly patients (≥65 years) and 30 middle-aged patients (45-64 years) who were scheduled for ophthalmic surgery and allocated them to the control or the device group. Anesthesia was maintained with 1.5% sevoflurane. Mild hypercapnic hyperventilation was induced by the ANEclear anesthesia recovery device. The primary outcome was the time from vaporizer shut-off to initial response (eye or mouth opening, nodding, or grasping hand) in elderly patients. The secondary outcomes were the time to extubation and leaving the operating room (OR), the time to reach 50% of the difference between BIS at extubation and vaporizer shut-off (BIS ET50), and interaction between the recovery measures and patient age. RESULTS: The ANEclear significantly reduced the time to initial response, extubation, leaving the OR, and BIS ET50 in both age groups: their means and 95% CI of the ratio of two means (Mean(ANEclear)/Mean(control)) were 0.576 (0.500, 0.660), 0.595 (0.523, 0.673), 0.713 (0.622, 0.812), and 0.547 (0.444, 0.663), respectively, in the elderly group, and 0.717 (0.591, 0.849), 0.723 (0.609, 0.842), 0.855 (0.736, 0.982), and 0.631 (0.463, 0.813), respectively, in the middle-aged group. The recovery measures were shortened equally in both age groups: P values for the interaction were 0.060679, 0.062534, 0.069215, and 0.420061, respectively. CONCLUSIONS: Recovery time was significantly decreased by the ANEclear in the elderly group. This reduction was comparable to the time for middle-aged patients.

Quantitative measurement of blood remifentanil concentration: development of a new method and clinical application.

We have developed a new detection method of blood remifentanil concentration using a gas chromatography-mass spectrometry(GC-MS) with fentanyl as the internal standard(IS). The detection was performed at m/z 168 and 245 for remifentanil and fentanyl, respectively. In addition, the retention times of remifentanil and fentanyl were 5 min 45 s and 6 min 51 s, respectively. The standard curve of relationship between remifentanil concentration and the ratio of the peak area of remifentanil to fentanyl was satisfactorily fitted as linear regression (R(2) = 0.998, p < 0.01). Intra- and inter-assay CV was 10.5 and 11.5 %, respectively. In the clinical setting, 21 adult patients undergoing elective surgery under propofol-remifentanil TIVA were enrolled. To determine blood remifentanil concentrations, arterial blood was obtained at 0-30 min after cessation of remifentanil infusion at 0.2 µg/kg/min. Blood samples were given into sample tubes(chilled on ice) containing citric acid 50 % 60 µl which inactivates all esterase, and then stored at -20 °C until assay. Measured blood remifentanil concentration was 3.59 ± 0.74 ng/ml at the end of remifentanil infusion, and the ime for a decrease in blood remifentanil concentration by half was ~2 min. Remifentanil concentration was below the detection limit 30 min after the cessation. Thus, we have confirmed that this new method is clinically applicable.

[A case of hypernatremia treated with human atrial natriuretic peptide].

We describe a case of 65-year-old obese female patient with pulmonary embolism and life-threatening hypernatremia after removal of craniopharyngioma. On the 18th day after neurosurgical procedure, pulmonary embolism developed abruptly. Immediately after placement of inferior vena cava filter, surgical removal of the pulmonary thrombus was performed under cardiopulmonary bypass. Although mechanical ventilatory support and infusion of noradrenaline were required postoperatively, the trachea was extubated on the 10th postoperative day. Meanwhile, daily serum Na level increased gradually and reached 178 mEq x l(-1). We suspected that dehydration and pituitary dysfunction were mainly responsible for the hypernatremia. Human atrial natriuretic peptide (hANP) was infused from the 2nd to the 4th postoperative day, and her urinary Na excretion became increased and serum Na level became normal. After discontinuation of hANP, urinary Na excretion became decreased again and serum Na levels increased transiently. However, her consciousness level and cardiopulmonary condition improved and she was discharged from the ICU after twelve days of ICU stay. HANP may be useful for treatment of life-threatening hypernatremia.

[Anesthetic management for EXIT (ex-utero intrapartum treatment) of a twin gestation: one normal and one with a large epignathus].

We experienced cesarean section of a twin gestation of which one was normal and the other had a large epignathus. Anesthesia was induced with rapid administration of propofol and suxamethonium, then her trachea was intubated and operation was started. Anesthesia was maintained with 3% sevoflurane in 100% oxygen. Five minutes from the start of the surgery, the first baby was born with Apgar score of 3/7. One minute later, the head of the second with large epignathus was out of the uterus. But we judged that her trachea was difficult to intubate, but she showed spontaneous respiration. Then we inserted a tracheal tube (ID 2 mm) to her nose for the airway, and she was carried into the infant warmer after amputating the umbilical cord. After the delivery, sevoflurane was discontinued, and propofol, fentanyl and ketamine were started. Cesarean section was finished with total blood loss of 1,900 g including amniotic fluid. In the infant warmer, tracheostomy was performed on the second baby, and the baby was carried to NICU. Thirteen days later, the epignathus was extracted without complication. General anesthesia with inhalational agent is usually chosen for cesarean section with EXIT. For EXIT, uterine relaxation and fetal akinesia are necessary, but deep inhalational anesthesia causes massive bleeding, hypotension and loss of spontaneous respiration of the fetus. Twin gestation with one normal and the other with airway trouble has many problems. We have to consider mother, normal baby and troubled baby during EXIT. We should treat them appropriately with prudence.

Successful treatment of acute respiratory distress syndrome after hysterectomy for life-threatening atonic bleeding by inhaled nitric oxide.

We report a case of a 33-year-old female who developed severe acute respiratory distress syndrome (ARDS) after emergency hysterectomy for life-threatening atonic bleeding. A marked decline in pulmonary oxygenation was observed during the surgery, which led to a diagnosis of ARDS. Following admission to the intensive care unit, hypoxia became critical, with a PaO(2)/F(I)O(2) value of 52 even after recruitment maneuvers. Inhaled nitric oxide (NO 10 ppm) was administered to the patient as a rescue treatment, resulting in a gradual but dramatic improvement in pulmonary oxygenation. Although several randomized trials have failed to confirm the beneficial effects of NO on morbidity in patients with ARDS, NO administration is worth consideration as treatment prior to invasive treatments, such as extracorporeal membrane oxygenation, for patients with acute lung injury/ARDS.

[Case of Rett syndrome monitored with BIS and neuromuscular monitor during total intravenous anesthesia].

We describe a case of 8-year-old female patient with Rett syndrome undergoing bilateral tonsillectomy and adenotomy. She was monitored with BIS and neuromuscular monitor using TOF during total intravenous anesthesia (TIVA) with propofol, remifentanil, ketamine and rocuronium. A relatively high infusion rate of propofol (10 mg x kg x hr(-1)) was maintained to keep BIS between 60 and 70 during the surgical procedure, and rocuronium 10 mg IV was administered for tracheal intubation without its further administration during the surgical procedure. Although prolonged effects of anesthetics, analgesics and neuromuscular blockade were reported frequently, she took uneventful course during anesthesia and surgery. Her recovery from anesthesia and neuromuscular blockade was also smooth associated with satisfactory sedated states. BIS and neuromuscular monitor may be useful in TIVA for a patient with Rett syndrome.

Combination of extracorporeal membrane oxygenation and high-frequency oscillatory ventilation saved a child with severe ARDS after pulmonary resection.

We report a case in which a 2-year-old girl who underwent a right middle and lower lung lobectomy for congenital cystic adenomatoid malformation suffered massive bleeding and developed acute respiratory distress syndrome (ARDS) during the operation. She was ventilated with a high level of F(I)O(2) (0.75-1.0), PEEP (10-20 cmH(2)O), and PIP (33-55 cmH(2)O) to maintain SPO(2) (>90%). Following transfer to the ICU, continuous hemodialysis was introduced to reduce excessive blood volume. However, pulmonary oxygenation did not improve, and marked subcutaneous emphysema occurred on postoperative day 3 (POD 3). We introduced venovenous (V-V) extracorporeal membrane oxygenation (ECMO) to rest the lung, and V-V ECMO was changed to right and left atrial ECMO because of unsatisfactory oxygen support on POD 23. A CT scan showed almost the entire lung had collapsed, even though we had administered diuretics, steroids, nitric oxide, sivelestat, and surfactant for ARDS. We applied high-frequency oscillatory ventilation (HFOV) with a mean airway pressure of 20 cmH(2)O, frequency of 9.2 Hz, and amplitude of 38 cmH(2)O on POD 45. The collapsed lung was then gradually recruited, and pulmonary oxygenation improved (P/F ratio = 434). ECMO was successfully weaned on POD 88. The patient required a tracheostomy, but she was able to function without a ventilator on POD 142. Although HFOV has failed to show a mortality benefit in ARDS patients, the unique lung recruitment by HFOV can be a useful therapeutic option for severe ARDS patients in combination with sufficient lung rest produced by ECMO.

Time-consumption risk of real-time ultrasound-guided internal jugular vein cannulation in pediatric patients: comparison with two conventional techniques.

To assess the efficacy of three different methods for internal jugular vein (IJV) cannulation in pediatric patients, we conducted a review of patients undergoing cardiovascular surgery over an 11-year period, in which success rates for cannulation and time from induction of anesthesia to cannulation were evaluated. The success rate was better for real-time ultrasound guidance (USG: 90%) than for anatomic landmarks (AL: 76%) or audio-Doppler guidance (ADG: 74%) and the time required was greater for USG (35.0 +/- 13.6 min) than for AL (26.7 +/- 11.2 min) or ADG (29.2 +/- 8.9 min). However, USG resulted in a higher success rate than the other methods with comparable procedure time for smaller-body-weight (<5 kg) patients. Thus real-time USG leads to the highest success rate for IJV cannulation but with a significant time delay, whereas it was the most useful without time delay for the smaller-body-weight subgroup.