A case of infective endocarditis associated with atopic dermatitis perioperatively treated with dupilumab.

Background: Several case reports and reviews support a relationship between atopic dermatitis (AD) and infective endocarditis (IE). Here, we present a case of severe AD suspected of causing IE. Case presentation: A 21-year-old man with severe AD was admitted to our hospital due to unidentified fever, syncope, and headache. He was diagnosed with IE with cerebral embolism and mitral regurgitation. Before elective cardiac surgery, he was subcutaneously administered dupilumab for 2 months to control AD. Dupilumab improved AD, and cardiac surgery was performed without complications. Conclusions: Dupilumab may be effective in AD cases as preparation for cardiac surgery.

Emergency cardiac surgery and heparin resistance in a patient with essential thrombocythemia.

A 66-year-old man with thrombocytosis was brought to our hospital to undergo removal of a left ventricular thrombus. He had developed cerebral infarction 6 days before presenting to the hospital and suffered from right incomplete hemiparalysis. Blood tests on admission revealed his platelet count to be 124.3 × 104/µl. The urgent removal operation was performed under general anesthesia. For carrying out extracorporeal circulation (ECC), approximately three times as much heparin as expected was needed, as well as antithrombin III (AT III) administration. This met the definition of heparin resistance. The thrombus was removed and surgical left ventricular reconstruction was performed. Aspirin and warfarin were initiated on postoperative day 5. A bone marrow biopsy was performed on postoperative day 8, which revealed hypercellular marrow with megakaryocyte proliferation, and the patient was diagnosed as having essential thrombocythemia (ET). Although hydroxycarbamide administration started on postoperative day 10, his platelet count increased to 290.7 × 104/µl on postoperative day 13. The counts descended gradually, and on postoperative day 34, his platelet count reached the normal range and he was discharged from the hospital. In the perioperative period, his new neurologic abnormality did not appear. Addition of heparin, administration of AT III, and coating the cardiopulmonary bypass circuit with heparin or macromolecular polymer prevented clot formation and enabled safe ECC in a patient with ET and a high platelet count.

[General Anesthesia for a Patient with Purulent Spondylitis with Retropharyngeal Abscess and Vocal Cord Dysfunction: A Case Report].

A 43-year-old man was admitted to our hospital for neck pain, and diagnosis was fixed as purulent spondylitis with retropharyngeal abscess and vocal cord dysfunction. Deteriorating paresthesia, paralysis and airway narrowing needed airway management emergency cervical laminoplasty and abscess drainage under general anesthesia. On standby of an otorhinolaryngologist for urgent tracheotomy, nasal tracheal intubation with bronchofiberscope was performed in the patient with semi-awake condition. Postoperative airway narrowing and vocal cord dysfunction improved, and the trachea was extubated on the third day after surgery.

[A Case of a Severely Burned Patient with Suspected Takotsubo Cardiomyopathy Who Underwent Immediate Excision and Skin Grafting under General Anesthesia].

An 88-year-old woman was severely burned on her thigh, leg, arm, buttocks, chest and abdomen in the bathroom and was emergently admitted to our hospital. The burn index was 10.8 and the prognostic burn index (PBI) was 99. The reports of echocardiography, cardiac biomarkers and electrocardiogram showed left ventricular dysfunction with apical akinesis, which was suspected as Takotsubo cardiomyopathy. To avoid poor prognosis because of severe PBI, immediate excision and skin grafting were performed under general anesthesia 23 hours after the burn onset. More infusion and transfusion than the expected amounts were needed during anesthesia and the postoperative 4 days because of cardiac failure and septic shock, which were overcome 14 days after the surgery. The complete early excision was impossible due to cardiac failure, and that the unexcised burn scar exacerbated infection and prevented her from survival.

Accelerated idioventricular rhythm observed under total intravenous anesthesia using remifentanil, propofol, and rocuronium.

Accelerated idioventricular rhythm (AIVR) during anesthesia has been described in several drug toxicity such as from cocaine, halothane, desflurane, and propofol. We present the case of a man who developed episodes of AIVR observed under total intravenous anesthesia (TIVA) using remifentanil, propofol, and rocuronium. AIVR during anesthesia was a benign phenomenon, and further examinations after surgery showed no structural heart disease and the daily occurrence of idioventricular arrhythmias. This case suggests that the suppression of sinus and atrioventricular nodal function and the autonomic imbalance caused by propofol and remifentanil may induce AIVR with greater frequency.

Ventricular tachycardia observed during cesarean section in a patient without structural cardiac disease.

A 32-year-old gravida 2, para 1 woman without structural cardiac disease was scheduled for her second cesarean section under combined spinal and epidural anesthesia (CSEA). She had stable hemodynamics after delivery; however, 16 min after the application of uterotonics, ventricular tachycardia (VT) with a heart rate (HR) of 150 bpm appeared. VT lasted for <30 s, and her hemodynamics remained stable. Ventricular arrhythmia frequently appeared for 3 min, and the HR at sinus rhythm was approximately 90 bpm. After the discontinuation of oxytocin, VT did not reappear. A postoperative 12-lead electrocardiogram showed first-degree atrioventricular block, but echocardiography performed 2 days later did not reveal any structural abnormalities. Autonomic nervous imbalance induced by CSEA, ephedrine, and oxytocin, as well as ergometrine may cause intraoperative VT during cesarean section in patients without structural cardiac disease.

[Case of lymphangioleiomyomatosis (LAM) discovered during cesarean section under spinal anesthesia].

We experienced a case of scheduled cesarean section under spinal anesthesia in a patient with LAM which had been missed in spite of preoperative medical examination and consultation with specialists but discovered because of perioperative hypoxia A 35-year-old woman, Gravida 1 Para 0, with breech presentation was scheduled to undergo cesarean section under spinal anesthesia at 38 weeks of gestation. She had no history of asthma or abnormal findings at annual medical examination. She had suffered from dry cough and nocturnal dyspnea for 7 weeks and an inhaled bronchodilator was administered with diagnosis of inflammatory airway disease by her respiratory physicians. Spinal anesthesia was performed with bupivacaine 12.5 mg. At the beginning of anesthesia SPO2 was 97% in supine position, but it rapidly decreased to less than 90% and 3 l x min(-1) oxygen was supplied with a facial mask. The anesthetic level was thoracal 4 bilaterally and her breathing was stable. The circulatory state, Apgar score and other vital signs were within normal ranges. Postoperative chest X-ray showed bilateral numerous grained spots and computed tomography scans showed multiple thin-walled cysts. The characteristic history and the fluoroscopic data gave her clinical diagnosis of LAM.

[The role of anesthesiologist in the palliative care team in a public hospital].

BACKGROUND: The Japanese government promotes palliative care and our hospital has the palliative care team including an anesthesiologist for better end of lives of cancer patients. METHODS: From the new point of an anesthesiologist, the outcome and characteristics of patients receiving palliative care in our hospital were examined. RESULTS: From August 2010 to March 2012, 93 patients were treated by the team. They were terminal patients whose remaining days were expected to be several months. The most common problem among them was severe pain amenable to opioid administration. CONCLUSIONS: Anesthesiologists familiar with pain, sedation and nausea control are important specialists in the palliative care team.

[Anesthetic management of a patient with thrombocytopenia induced by methotrexate undergoing emergent clipping surgery].

A 70-year-old woman underwent emergent clipping surgery for subarachnoid hemorrhage under general anesthesia. Her laboratory data showed thrombocytopenia (4.0 x 10(4) microl(-1)). She had taken prednisolone (3 mg x day(-1)) and methotrexate (MTX) (10 mg x week(-1)) for rheumatoid arthritis for the last 10 years. Anesthesia was induced with remifentanil as well as propofol, maintained with remifentanil and sevoflurane in oxygen. The operation was performed uneventfully without platelet transfusion. Since the cause of thrombocytopenia was suspected to be MTX, we started rescue therapy by calcium folinate postoperatively. Platelet count was normalized two days later (11.6 x 10(4) microl(-1)). One month after the operation, she was discharged uneventfully.

[Uncrossmatched type O red blood cell transfusion and cell saver autologous blood transfusion effective for intraoperative massive bleeding].

We experienced rapid and massive bleeding in a 57-year-old woman undergoing resection of ovarian tumor metastasis. One hour after the start of operation, blood loss increased due to adhesion of the tumor. The blood hemoglobin level decreased from 11.7 to 4.6 g x dl(-1). Since available matched homologous blood had been consumed, we transfused type O uncrossmatched red blood cells followed by cell saver autologous blood. For the treatment of uncontrollable hyperkalemia and metabolic acidosis, continuous hemodiafiltration was started. A total of 66 U of red blood cells, 48 U of FFP, and 40 U of platelets were transfused intraoperatively. No neurological deficit, pulmonary edema, renal failure, or hemolysis was found postoperatively.

The effects of general anesthetics on P2X7 and P2Y receptors in a rat microglial cell line.

BACKGROUND: Microglial cells play important roles in coordinating the inflammatory brain responses to hypoxia and trauma. Ionotropic P2X receptors and metabotropic P2Y receptors (P2YRs) expressed in microglia can be activated by extracellular adenosine triphosphate (ATP) derived from damaged cells or astrocytes, and participate in the signaling pathways evoked in brain insult. Although several inhaled and IV anesthetics produce neuroprotective effects through neuronal mechanisms, little is known about how general anesthetics modulate microglial responses in the pathological state. We examined the effects of various general anesthetics on purinergic responses in a rat microglial cell line. METHODS: Currents were consistently activated by applications of ATP via a U-tube system under the whole-cell configuration. ATP-induced nondesensitizing currents observed after several applications of ATP exhibited characteristics of P2X7 receptors. The P2YRs-mediated mobilization of intracellular Ca2+ was measured using a Ca2+-sensitive fluorescent dye (fura-2). RESULTS: Inhaled anesthetics (sevoflurane, isoflurane, and halothane) at doses three times as high as minimum alveolar concentrations had no effect on the P2X7Rs-mediated currents. IV anesthetics (ketamine, propofol, and thiopental) enhanced the P2X7Rs-mediated currents reversibly. The potencies for activation of P2X7Rs were not correlated with the octanol/buffer partition coefficients. Thiopental, at low concentrations, slightly inhibited the P2X7Rs-mediated currents, suggesting its dual actions on P2X7Rs. The P2YRs-mediated mobilization of intracellular Ca2+ was not affected by any of the general anesthetics tested. CONCLUSIONS: Our results suggest that IV anesthetics, particularly thiopental and propofol, may modulate microglial functions through P2X7Rs in pathological conditions.

[The use of questionnaires for rotating residents in evaluating training in anesthesiology].

BACKGROUND: We prepared questionnaires for the rotating residents during their assignment for anesthesiology in the novel Japanese residency programs for the year 2004. METHODS: Questionnaires consisting of 39 items with 235 model answers for these items were prepared. The residents underwent three interviews by these questionnaires over the three-month training period. The number of correct answers for these questionnaires was recorded and evaluated using a computer database software. RESULTS: There was no significant correlation between the results of these questionnaires and the subjective evaluation by supervisors conducted during clinical training. On stepwise regression analysis, the results of the questionnaires for "American Society of Anesthesiologists Physical Status", "contraindications for epidural anesthesia", "complications of general anesthesia" and "initial procedures for patients in the operating room" correlated with the subjective evaluation by supervisors. CONCLUSIONS: Stepwise regression analysis was shown to be helpful in improving the questionnaires regarding the training in anesthesiology.