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Predictive model for post-induction hypotension in patients undergoing transcatheter aortic valve implantation: a retrospective observational study. JA Clin Rep 2024; 10:33. [PMID: 38787499 PMCID: PMC11126397 DOI: 10.1186/s40981-024-00717-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/26/2024] [Accepted: 05/19/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Post-induction hypotension (PIH) is an independent risk factor for prolonged postoperative stay and hospital death. Patients undergoing transcatheter aortic valve implantation (TAVI) are prone to develop PIH. This study aimed to develop a predictive model for PIH in patients undergoing TAVI. METHODS This single-center retrospective observational study included 163 patients who underwent TAVI. PIH was defined as at least one measurement of systolic arterial pressure <90 mmHg or at least one incident of norepinephrine infusion at a rate >6 µg/min from anesthetic induction until 20 min post-induction. Multivariate logistic regression analysis was performed to develop a predictive model for PIH in patients undergoing TAVI. RESULTS In total, 161 patients were analyzed. The prevalence of PIH was 57.8%. Multivariable logistic regression analysis showed that baseline mean arterial pressure ≥90 mmHg [adjusted odds ratio (aOR): 0.413, 95% confidence interval (95% CI): 0.193-0.887; p=0.023] and higher doses of fentanyl (per 1-µg/kg increase, aOR: 0.619, 95% CI: 0.418-0.915; p=0.016) and ketamine (per 1-mg/kg increase, aOR: 0.163, 95% CI: 0.062-0.430; p=0.002) for induction were significantly associated with lower risk of PIH. A higher dose of propofol (per 1-mg/kg increase, aOR: 3.240, 95% CI: 1.320-7.920; p=0.010) for induction was significantly associated with higher risk of PIH. The area under the curve (AUC) for this model was 0.802. CONCLUSION The present study developed predictive models for PIH in patients who underwent TAVI. This model may be helpful for anesthesiologists in preventing PIH in patients undergoing TAVI.
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Association between preoperative neutrophil-lymphocyte ratio, uric acid, and postoperative delirium in elderly patients undergoing degenerative spine surgery. J Anesth 2024; 38:35-43. [PMID: 37898990 DOI: 10.1007/s00540-023-03273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 10/04/2023] [Indexed: 10/31/2023]
Abstract
PURPOSE There are few reports regarding the association between the neutrophil-lymphocyte ratio (NLR), uric acid, and the development of postoperative delirium (POD) in patients who are undergoing spine surgeries. We investigated the associations between the NLR, uric acid as a natural antioxidant, and POD in elderly patients undergoing degenerative spine surgery. PATIENTS AND METHODS This was a single-center, observational, and retrospective study conducted in Japan. We enrolled 410 patients who underwent degenerative spine surgery. POD was diagnosed after the surgeries by psychiatrists, based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). We performed a multivariable logistic regression analysis to clarify whether the NLR and uric acid values were associated with the development of POD in the patients. RESULTS 129 of the 410 patients were excluded from the analysis. Of the 281 patients (137 females, 144 males), 32 patients (11.4%) were diagnosed with POD. The multivariable logistic regression analysis revealed that the preoperative uric acid level (adjusted odds ratio [aOR]: 0.67, 95% confidence interval [CI]: 0.49-0.90, p = 0.008) and age (aOR: 1.09, 95% CI: 1.02-1.16, p = 0.008) were significantly associated with POD. The preoperative NLR (aOR: 0.82, 95% CI: 0.60-1.13, p = 0.227) and antihyperuricemic medication (aOR: 0.97, 95% CI: 0.24-3.82, p = 0.959) were not significantly associated with POD. CONCLUSION Our results demonstrated that in elderly patients undergoing degenerative spine surgery, the preoperative NLR was not significantly associated with POD, but a lower preoperative uric acid value was an independent risk factor for developing POD. Uric acid could have a neuroprotective impact on POD in patients with degenerative spine diseases.
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The Perioperative Frontal Relative Ratio of the Alpha Power of Electroencephalography for Predicting Postoperative Delirium After Highly Invasive Surgery: A Prospective Observational Study. Anesth Analg 2023; 137:1279-1288. [PMID: 36917508 DOI: 10.1213/ane.0000000000006424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND We investigated the associations between postoperative delirium (POD) and both the relative ratio of the alpha (α)-power of electroencephalography (EEG) and inflammatory markers in a prospective, single-center observational study. METHODS We enrolled 84 patients who underwent radical cancer surgeries with reconstruction for esophageal cancer, oral floor cancer, or pharyngeal cancer under total intravenous anesthesia. We collected the perioperative EEG data and the perioperative data of the inflammatory markers, including neutrophil gelatinase-associated lipocalin, presepsin, procalcitonin, C-reactive protein, and the neutrophil-lymphocyte ratio (NLR). The existence of POD was evaluated based on the Intensive Care Delirium Screening Checklist. We compared the time-dependent changes in the relative ratio of the EEG α-power and inflammatory markers between the patients with and without POD. RESULTS Four of the 84 patients were excluded from the analysis. Of the remaining 80 patients, 25 developed POD and the other 55 did not. The relative ratio of the α-power at baseline was significantly lower in the POD group than the non-POD group (0.18 ± 0.08 vs 0.28 ± 0.11, P < .001). A time-dependent decline in the relative ratio of α-power in the EEG during surgery was observed in both groups. There were significant differences between the POD and non-POD groups in the baseline, 3-h, 6-h, and 9-h values of the relative ratio of α-power. The preoperative NLR of the POD group was significantly higher than that of the non-POD group (2.88 ± 1.04 vs 2.22 ± 1.00, P < .001), but other intraoperative inflammatory markers were comparable between the groups. Two multivariable logistic regression models demonstrated that the relative ratio of the α-power at baseline was significantly associated with POD. CONCLUSIONS Intraoperative frontal relative ratios of the α-power of EEG were associated with POD in patients who underwent radical cancer surgery. Intraoperative EEG monitoring could be a simple and more useful tool for predicting the development of postoperative delirium than measuring perioperative acute inflammatory markers. A lower relative ratio of α-power might be an effective marker for vulnerability of brain and ultimately for the development of POD.
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Acute coronary syndrome due to left main coronary trunk compression 2 months after left atrial auricle clipping: a case report. JA Clin Rep 2023; 9:42. [PMID: 37438473 DOI: 10.1186/s40981-023-00634-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Left atrial auricle (LAA) clipping is a common method of preventing cardiogenic thromboembolism. However, acute coronary syndrome (ACS) has been reported as a fatal complication of LAA clipping. We describe a case of ACS 2 months after LAA clipping. CASE PRESENTATION A 33-year-old male with atrial fibrillation was scheduled LAA clipping during aortic valve replacement for congenital aortic bicuspid valve. The surgery went smoothly with no postoperative complications, but he suddenly went into cardiac arrest 2 months later. Emergency coronary angiography and intravascular ultrasonography revealed that compression by the clip of the left main coronary trunk had caused the ACS. Percutaneous coronary intervention with stents was performed, and the clip was removed under general anesthesia. CONCLUSION Even in the remote timepoint of LAA clipping, compression of the coronary artery by the clip should be differentiated as a cause of ACS.
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Anesthetic management with remimazolam in a patient with Child-Pugh C liver cirrhosis: a case report. JA Clin Rep 2022; 8:99. [PMID: 36572840 PMCID: PMC9792621 DOI: 10.1186/s40981-022-00590-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Remimazolam is a new ultra-short-acting benzodiazepine, and its sedative effect is prolonged in patients with hepatic impairment. This is the first report of remimazolam anesthesia in a patient with Child-Pugh C liver cirrhosis. CASE PRESENTATION A 52-year-old female was diagnosed with tongue cancer and scheduled for partial glossectomy. Preoperative examinations revealed Child-Pugh C liver cirrhosis, but the pathogenesis was unknown. We scheduled remimazolam anesthesia because it would stabilize her intraoperative circulation. We managed with a much lower-than-normal dose of remimazolam; even so, the patient required flumazenil to regain consciousness. She was admitted to the intensive care unit, but her consciousness remained clear even after the effect of flumazenil had worn off. CONCLUSION We experienced anesthetic management with remimazolam in a patient with Child-Pugh C liver cirrhosis. Even conservative use of remimazolam in patients with severe hepatic dysfunction may result in emergence times that are delayed longer than expected.
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Delayed emergence due to remimazolam extravaation. JA Clin Rep 2022; 8:96. [PMID: 36484880 PMCID: PMC9733729 DOI: 10.1186/s40981-022-00584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022] Open
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Anesthetic management of a patient with subclinical myasthenia gravis who underwent a thymectomy: a case report. JA Clin Rep 2022; 8:49. [PMID: 35835969 PMCID: PMC9283611 DOI: 10.1186/s40981-022-00541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/24/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Some individuals with subclinical myasthenia gravis (MG) are positive for serum anti-acetylcholine receptor antibodies, without neurological symptoms. There are no anesthetic management guidelines for subclinical MG. We report the anesthetic management of a patient with subclinical MG who underwent a thymectomy. Case presentation A 57-year-old female with subclinical MG was scheduled for an extended thymectomy. Anesthesia was induced and maintained with mainly propofol and remifentanil. We administrated the minimum amount of rocuronium with reference to train-of-four (TOF) monitoring when a neuromuscular relaxant is needed. Although the prolonged effect of rocuronium was observed, the TOF ratio had already recovered to 100% before the tracheal extubation. Postoperative analgesia was performed by a continuous epidural infusion of levobupivacaine. Conclusion We reported the anesthetic management of a patient with subclinical MG who underwent a thymectomy. Further research is necessary to clarify subclinical MG patients' sensitivity to rocuronium.
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Bedside insertion of a peripherally inserted central catheter into a patient with BMI of 84.8 kg/m2 using a magnetic tracking and electrocardiogram-based tip confirmation system: a case report. JA Clin Rep 2022; 8:69. [PMID: 36029359 PMCID: PMC9420167 DOI: 10.1186/s40981-022-00559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Peripherally inserted central catheters (PICCs) are typically placed under fluoroscopy. We used a magnetic tracking and electrocardiogram-based tip confirmation system for insertion of a PICC insertion in a morbidly obese patient at the bedside.
Case presentation
A 53-year-old female with severe obesity (height, 160 cm; weight, 217 kg; BMI, 84.8 kg/m2) was admitted to the intensive care unit. Both bilateral, inguinal, and cervical regions were covered with an excess of adipose tissue, making it difficult to place a central venous line. Since transferring her to fluoroscopy seemed dangerous, a PICC was inserted using Sherlock 3CG® TCS at the bedside. Magnetic sensor guidance failed due to the thick subcutaneous tissue her precordium, but intracavity electrocardiography could direct the tip to an appropriate position.
Conclusion
We experienced bedside insertion of a PICC into a patient with BMI of 84.8 kg/m2 patient using a Sherlock 3CG® TCS. Since the interaction between Sherlock 3CG® TCS and body habitus has not been investigated, further reports are needed.
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Acute normovolemic hemodilution reduced the frequency and amount of perioperative allogeneic blood transfusion in pediatric and adolescent scoliosis surgery: a retrospective observational study. J Anesth 2022; 36:484-492. [PMID: 35676440 DOI: 10.1007/s00540-022-03078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the present study is to investigate whether acute normovolemic hemodilution (ANH) can reduce the frequency and amount of perioperative allogeneic blood transfusion (ABT) (intraoperative ABT and postoperative ABT until discharge from the hospital) in pediatric and adolescent scoliosis surgery. METHODS This single-center, retrospective, observational study included the perioperative data of 147 patients who were 18 years old or younger and underwent scoliosis surgery. Patients were divided into groups according to whether they received ANH: i.e., an ANH group and control group. Propensity-score-adjusted multivariable logistic regression analysis was performed to determine whether ANH can reduce the frequency of perioperative ABT. RESULTS A total of 125 patients were analyzed, 95 and 30 in the ANH and control group, respectively. The intraoperative/postoperative ABT frequency was significantly lower in the ANH group than in the control group (17.9% vs. 36.7%, p = 0.044). The amount of ABT [median (IQR): 0 (0, 0) mL/kg vs. 0 (0, 16.3) mL/kg, p = 0.033] was also significantly lower in the ANH group than in the control group. Propensity-score-adjusted multivariable logistic regression analysis indicated that ANH use [odds ratio: 0.15; 95% confidence interval: 0.03, 0.77; p = 0.023)] was associated with a lower risk of ABT after adjusting for intraoperative blood loss and duration of surgery. CONCLUSION ANH use can reduce the frequency and amount of perioperative ABT in pediatric and adolescent scoliosis surgery.
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Publisher Correction: Higher neutrophil-lymphocyte ratio is associated with depressive symptoms in Japanese general male population. Sci Rep 2022; 12:11770. [PMID: 35817841 PMCID: PMC9273614 DOI: 10.1038/s41598-022-15967-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Predict models for prolonged ICU stay using APACHE II, APACHE III and SAPS II scores: A Japanese multicenter retrospective cohort study. PLoS One 2022; 17:e0269737. [PMID: 35709080 PMCID: PMC9202898 DOI: 10.1371/journal.pone.0269737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Prolonged ICU stays are associated with high costs and increased mortality. Thus, early prediction of such stays would help clinicians to plan initial interventions, which could lead to efficient utilization of ICU resources. The aim of this study was to develop models for predicting prolonged stays in Japanese ICUs using APACHE II, APACHE III and SAPS II scores. In this multicenter retrospective cohort study, we analyzed the cases of 85,558 patients registered in the Japanese Intensive care Patient Database between 2015 and 2019. Prolonged ICU stay was defined as an ICU stay of >14 days. Multivariable logistic regression analyses were performed to develop three predictive models for prolonged ICU stay using APACHE II, APACHE III and SAPS II scores, respectively. After exclusions, 79,620 patients were analyzed, 2,364 of whom (2.97%) experienced prolonged ICU stays. Multivariable logistic regression analyses showed that severity scores, BMI, MET/RRT, postresuscitation, readmission, length of stay before ICU admission, and diagnosis at ICU admission were significantly associated with higher risk of prolonged ICU stay in all models. The present study developed predictive models for prolonged ICU stay using severity scores. These models may be helpful for efficient utilization of ICU resources.
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Higher neutrophil-lymphocyte ratio is associated with depressive symptoms in Japanese general male population. Sci Rep 2022; 12:9268. [PMID: 35661149 PMCID: PMC9166769 DOI: 10.1038/s41598-022-13562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/25/2022] [Indexed: 11/10/2022] Open
Abstract
Relationships between the neutrophil–lymphocyte ratio (NLR) and/or the platelet-lymphocyte ratio (PLR) and neuroinflammatory diseases have been reported. Depression is also associated with neuroinflammation. Here, we determined the association between the NLR, PLR, and depressive symptoms. This cross-sectional study is a secondary analysis of the data of the Iwaki Health Promotion Project 2017. We analyzed the characteristics and laboratory data of 1,015 Japanese subjects (597 females, 408 males) including their NLR and PLR values. We assigned the subjects with a Center for Epidemiologic Studies Depression Scale (CES-D) score ≥ 16 to the depressive symptoms group. We performed a multivariate logistic regression analysis to determine whether the NLR and/or PLR were associated with depressive symptoms (CES-D ≥ 16). Two hundred subjects (19.7%; 122 [20.4%] females, 78 [19.1%] males) were assigned to the depressive symptoms group. There were significant differences between the non-depressive symptoms and depressive symptoms groups in the NLR [median (25th to 75th percentile): 1.54 (1.24, 1.97) vs. 1.76 (1.32, 2.37), P = 0.005] and the PLR [median (25th to 75th percentile): 123.7 (102.0, 153.9) vs. 136.8 (107.0, 166.5), P = 0.047] in males, but not in females. The multivariate logistic regression analysis demonstrated that the NLR was significantly associated with depressive symptoms in males (adjusted odds ratio: per 1 increase, 1.570; 95% confidence interval: 1.120–2.220; P = 0.009). In conclusion, our findings indicate that higher NLR may be associated with depressive symptoms in males.
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Two cases of circulatory collapse due to suspected remimazolam anaphylaxis. JA Clin Rep 2022; 8:18. [PMID: 35249154 PMCID: PMC8898805 DOI: 10.1186/s40981-022-00508-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background Remimazolam was approved in Japan in January 2020. We report two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. Case presentation Case 1: A 74-year-old male was scheduled for debridement and skin grafting for a severe burn injury. We induced anesthesia with 4 mg of remimazolam and 20 mg of ketamine. The patient subsequently developed treatment-resistant severe hypotension. Case 2: A 59-year-old male was scheduled for laparoscopic-assisted sigmoid colectomy. We induced anesthesia with 9 mg of remimazolam. Within a few minutes, the patient developed treatment-resistant severe hypotension. As serum tryptase was elevated in both cases and only intravenous administration of adrenaline was effective, we considered the circulatory collapse might be due to anaphylaxis. Conclusion We experienced two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. The prevalence of remimazolam anaphylaxis is not yet known, and further research is needed.
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Plasma orexin A does not reflect severity of illness in the intensive care units patients with systemic inflammation. JA Clin Rep 2022; 8:7. [PMID: 35064847 PMCID: PMC8783934 DOI: 10.1186/s40981-022-00498-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/14/2022] [Accepted: 01/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Systemic inflammatory response occurs by sepsis and invasive surgery. Recent articles suggest that not only CRP but also procalcitonin, presepsin, and neutrophil gelatinase-associated lipocalin may reflect the severity of systemic inflammation. In addition, as systemic inflammation could degenerate orexin neurons, plasma orexin A might also be a good biomarker to predict the severity. Thus, we have determined relation between plasma biomarker and severity of illness score in patients with systemic inflammation.
Methods
Previous database (UMIN000018427) was used to secondly determine which plasma biomarkers may predict the severity of illness in the ICU patients with systemic inflammation (n = 57, 31 non-sepsis surgical patients and 26 sepsis patients). We measured plasma levels of orexin A, CRP, procalcitonin, presepsin, and neutrophil gelatinase-associated lipocalin were measured, and APACHE II score was assessed in these patients at their admission to the ICU. Data are shown as mean ± SD. Statistical analyses were done with unpaired t test. The correlation between APACHE II score and plasma biomarkers were examined using Pearson’s correlation coefficient and a least squares linear regression line.
Results
Demographic data did not differ between sepsis and non-sepsis groups. However, APACHE-II score was significantly higher in sepsis group than those in non-sepsis group (20.9 ± 6.6 vs 15.8 ± 3.2, p < 0.01). There were significant correlations between APACHE II score and plasma CRP (r = 0.532, p < 0.01), procalcitonin (r = 0.551, p < 0.01), presepsin (r = 0.510, p < 0.01), and neutrophil gelatinase-associated lipocalin (r = 0.466, P < 0.01) except orexin A.
Conclusion
All plasma biomarkers tested except orexin A may reflect the severity of illness in patients with systemic inflammation.
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The role of neutrophil gelatinase-associated lipocalin and iron homeostasis in object recognition impairment in aged sepsis-survivor rats. Sci Rep 2022; 12:249. [PMID: 34997032 PMCID: PMC8742111 DOI: 10.1038/s41598-021-03981-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022] Open
Abstract
Older adult patients with sepsis frequently experience cognitive impairment. The roles of brain neutrophil gelatinase-associated lipocalin (NGAL) and iron in older sepsis patients remain unknown. We investigated the effects of lipopolysaccharide-induced sepsis on novel object recognition test, NGAL levels, an inflammatory mediator tumor necrosis factor-α (TNFα) levels, and iron ion levels in the hippocampus and cortex of young and aged rats. The effect of an iron chelator deferoxamine pretreatment on aged sepsis rats was also examined. Young sepsis-survivor rats did not show impaired novel object recognition, TNFα responses, or a Fe2+/Fe3+ imbalance. They showed hippocampal and cortical NGAL level elevations. Aged sepsis-survivor rats displayed a decreased object discrimination index, elevation of NGAL levels and Fe2+/Fe3+ ratio, and no TNFα responses. Pretreatment with deferoxamine prevented the reduction in the object recognition of aged sepsis-survivor rats. The elevation in hippocampal and cortical NGAL levels caused by lipopolysaccharide was not influenced by deferoxamine pretreatment. The lipopolysaccharide-induced Fe2+/Fe3+ ratio elevation was blocked by deferoxamine pretreatment. In conclusion, our findings suggest that iron homeostasis in the cortex and hippocampus contributes to the maintenance of object recognition ability in older sepsis survivors.
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Higher neutrophil-to-lymphocyte ratio, mean platelet volume, and platelet distribution width are associated with postoperative delirium in patients undergoing esophagectomy: a retrospective observational study. J Anesth 2021; 36:58-67. [PMID: 34595569 DOI: 10.1007/s00540-021-03007-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/24/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE We investigated whether preoperative inflammatory markers, i.e., the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), and platelet distribution width (PDW) can predict the development of postoperative delirium (POD) after esophagectomy. PATIENTS AND METHODS This single-center, retrospective, observational study included 110 patients who underwent an esophagectomy. We assigned the patients with the Intensive Care Delirium Screening Checklist score ≥ 4 to the POD group. We performed multivariable logistic regression analyses to determine whether the NLR, PLR, MPV, and PDW can be used to predict the development of POD. RESULTS The POD group had 20 patients; the non-POD group included the other 90 patients. Although only the preoperative NLR in the POD group was significantly higher than in the non-POD group (3.20 [2.52-4.30] vs. 2.05 [1.45-3.02], p = 0.001), multivariable logistic regression analyses showed that the following three parameters were independent predictors of POD: preoperative NLR ≥ 2.45 (adjusted odds ratio [aOR]: 8.68, 95%CI 2.33-32.4, p = 0.001), MPV ≥ 10.4 (aOR: 3.93, 95%CI: 1.37-11.2, p = 0.011), and PDW ≥ 11.8 (aOR: 3.58, 95%CI: 1.22-10.5, p = 0.020). CONCLUSION Our analysis results demonstrated that preoperative NLR ≥ 2.45, MPV ≥ 10.4, and PDW ≥ 11.8 were significantly associated with a higher risk of POD after adjustment for possible confounding factors. However, as the AUCs of the preoperative MPV and PDW for the prediction of the development of POD in univariable ROC analyses were low, large prospective studies are needed to confirm this result.
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Availability of preoperative neutrophil-lymphocyte ratio to predict postoperative delirium after head and neck free-flap reconstruction: A retrospective study. PLoS One 2021; 16:e0254654. [PMID: 34255810 PMCID: PMC8277034 DOI: 10.1371/journal.pone.0254654] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/30/2021] [Indexed: 01/04/2023] Open
Abstract
Postoperative delirium (POD) is a well-recognized postoperative complication and is associated with increased morbidity and mortality. We investigated whether the preoperative neutrophil-lymphocyte ratio (NLR) could be an effective predictor of POD after head and neck free-flap reconstruction. This was a single-center, retrospective, observational study. We analyzed the perioperative data of patients who had undergone elective head and neck free-flap reconstruction surgery. POD was assessed with the Intensive Care Delirium Screening Checklist (ICDSC) during admission to our intensive care unit (ICU). POD was defined as an ICDSC score ≥4. Risk factors for POD were evaluated by univariate and multivariate logistic regression analysis. We included 97 patients. The incidence of POD was 20.6% (20/97). Significantly longer ICU stays were observed in the patients with POD compared to those without POD (median [interquartile range]: 5 [4–6] vs. 4 [4–5], p = 0.031). Higher preoperative NLR values (3 <NLR ≤4 and 4 <NLR) were significantly associated with higher ICDSC scores compared to NLR ≤1 (4 [2–4] vs. 1 [1–1], p = 0.027 and 4 [1–4] vs. 1 [1–1], p = 0.038, respectively). The multivariable logistic regression analysis revealed that only a preoperative NLR >3.0 (adjusted Odds Ratio: 23.6, 95% Confidence Interval: 6.6–85.1; p<0.001) was independently associated with POD. The multivariate area under the receiver operator curve was significantly greater for the E-PRE-DELIRIC model with NLR compared to the E-PRE-DELIRIC model (0.87 vs. 0.60; p<0.001). The preoperative NLR may be a good predictor of POD in patients undergoing head and neck free-flap reconstruction.
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Roles of Neuropeptide S in Anesthesia, Analgesia, and Sleep. Pharmaceuticals (Basel) 2021; 14:ph14050483. [PMID: 34069327 PMCID: PMC8158725 DOI: 10.3390/ph14050483] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 02/07/2023] Open
Abstract
Neuropeptide S (NPS) is an endogenous peptide that regulates various physiological functions, such as immune functions, anxiety-like behaviors, learning and memory, the sleep–wake rhythm, ingestion, energy balance, and drug addiction. These processes include the NPS receptor (NPSR1). The NPS–NPSR1 system is also significantly associated with the onset of disease, as well as these physiologic functions. For example, NPS is involved in bronchial asthma, anxiety and awakening disorders, and rheumatoid arthritis. In this review, among the various functions, we focus on the role of NPS in anesthesia-induced loss of consciousness; analgesia, mainly by anesthesia; and sleep–wakefulness. Progress in the field regarding the functions of endogenous peptides in the brain, including NPS, suggests that these three domains share common mechanisms. Further NPS research will help to elucidate in detail how these three domains interact with each other in their functions, and may contribute to improving the quality of medical care.
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Perioperative abnormal electroencephalography in a later-stage elderly with septic shock: a case report. JA Clin Rep 2021; 7:5. [PMID: 33404769 PMCID: PMC7786879 DOI: 10.1186/s40981-020-00409-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/04/2020] [Accepted: 12/26/2020] [Indexed: 11/17/2022] Open
Abstract
Background Patients with sepsis often exhibit abnormal patterns of electroencephalogram (EEG). We report an abnormal EEG pattern in a later-stage elderly patient with septic shock and EEG analysis results. Case presentation An 88-year-old woman with bowel perforation underwent emergency Hartmann surgery. On admission to the operating room, she exhibited septic shock. Her bispectral index value was 30 before anesthesia induction, and the EEG displayed slow waves without burst and suppression throughout the surgery. The relative slow-wave ratio [spectral power (0.5–8 Hz)/(0.5–30 Hz)] from anesthetic induction to the end of surgery was 95.1%, whereas the relative alpha frequency [spectral power (8–13 Hz)/(0.5–30 Hz)] was only 2.4%. Although without preoperative neurological abnormalities, she developed postoperative delirium after admission to the intensive care unit. Conclusions Intraoperative continuous EEG monitoring in elderly patients with sepsis may be useful to predict sepsis-associated encephalopathy. Therefore, continuous EEG monitoring may improve neurological outcomes.
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Lower fractional exhaled nitric oxide levels are associated with depressive symptom in males: A population-based cross-sectional study. Psychiatry Res 2020; 293:113453. [PMID: 32971403 DOI: 10.1016/j.psychres.2020.113453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/13/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND We examined cross-sectional associations between depression and both inflammatory markers and fractional exhaled nitric oxide (FeNO). METHODS This cross-sectional study is a secondary analysis of the data of the Iwaki Health Promotion Project 2016 (1,148 subjects). We analyzed the subjects' characteristics and laboratory data including plasma interleukin (IL)-6, high-sensitivity C-reactive protein (hs-CRP), and FeNO. The subjects with Center for Epidemiologic Studies Depression Scale scores ≥16 were assigned to the depression group. We performed a multivariate logistic regression analysis to determine whether inflammatory markers and FeNO were associated with depression. RESULTS We assessed 1,099 subjects (430 males, 669 females). The depression group was 237 subjects (21.5%) [84 males (19.5%), 153 females (22.9%)]. The non-depression group was 862 subjects (346 males and 516 females). There were no significant differences in IL-6, hs-CRP, or FeNO between both groups. However, the multivariate logistic regression analysis indicated that lower FeNO was significantly associated with depression in males after adjusting for possible confounding factors (age, BMI, comorbidities, high-sensitivity troponin T, FEV1%, asthma, antidepressant use, smoker and alcohol drinker) (per 1 bpm increase, OR: 0.982; 95%CI: 0.967-0.998; p = 0.032). CONCLUSION Our findings indicate that lower FeNO may be associated with depression in males.
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Clotting functional stability of withdrawing blood in storage for acute normovolemic hemodilution: a pilot study. J Anesth 2020; 35:35-42. [PMID: 32975715 PMCID: PMC7840648 DOI: 10.1007/s00540-020-02856-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/12/2020] [Indexed: 11/06/2022]
Abstract
Purpose This study was conducted to time-course changes of clotting function of withdrawing blood for acute normovolemic hemodilution (ANH). Methods Twelve enrolled patients who underwent ANH from August, 2018 to January, 2019. Blood was withdrawn into blood collection pack and shaken at 60–80 rpm for 24 h in room temperature. Clot formation was evaluated using rotational thromboelastometry (ROTEM™) just after blood withdrawal (control) and 4, 8, 12 and 24 h after blood withdrawal. We compared with the control value and each value of extrinsically-activated test with tissue factor (EXTEM), intrinsically-activated test using ellagic acid (INTEM) and fibrin-based extrinsically activated test with tissue factor (FIBTEM). Results Maximum clot firmness (MCF) of FIBTEM did not change significantly. MCF of EXTEM was significantly decreased time-dependent manner but all MCF of EXTEM were within a normal range. Maximum percent change in MCF of EXTEM was 12.4% [95% confidence interval (CI): 9.0–15.8%]. The difference in the maximum clot elasticity (MCE) between EXTEM and FIBTEM (MCEEXTEM−MCEFIBTEM) was significantly decrease from 8 h after blood withdrawal. Maximum percent change in MCEEXTEM−MCEFIBTEM was 30.2% (95% CI:17.6–42.9%) at 24 h after blood withdrawal. Conclusion Even though the MCE significantly decreased in a time-dependent manner, MCF of FIBTEM and EXTEM was normal up to 24 h storage. The blood of ANH can use for the purpose of hemostasis at least 8 h stored at room temperature after blood withdrawal. Future studies are needed to elucidate the clinical impact on the patient after delayed transfusion of ANH blood with regard to patient’s hemostasis. Electronic supplementary material The online version of this article (10.1007/s00540-020-02856-x) contains supplementary material, which is available to authorized users.
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Is neurotransmitter release involved in the mechanism of general anesthesia? J Anesth 2019; 34:153-155. [PMID: 31792666 DOI: 10.1007/s00540-019-02718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/22/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION It is believed that neurotransmitters release modulates general anesthesia via several receptors system which are molecular targets for anesthetic agents in young-adult rats. However, middle-aged rats have rarely been used. Therefore, we studied in this age group. MATERIALS AND METHODS After approval of our protocol by the institutional committee on animal research, 116 middle aged Sprague-Dawley rats were assigned to ketamine (K: n = 74) and propofol (P: n = 42) anesthesia groups. Rats were decapitated 0, 20 60 and 120 min after ip K (100 mg/kg) or P (80 mg/kg), respectively. Melanin-concentrating hormone (MCH), orexin A (OXA) and noradrenaline contents in the pons, hypothalamus, hippocampus and cerebrocortex were measured by a commercial enzyme-linked immunosorbent assay (ELISA) or high-performance liquid chromatography. RESULTS Neurotransmitter content in all brain regions did not significantly change following K or P administration. CONCLUSION Therefore, we question whether neurotransmitter release contributes to general anesthesia.
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Acute normovolemic hemodilution reduced allogeneic blood transfusion without increasing perioperative complications in patients undergoing free-flap reconstruction of the head and neck. J Anesth 2019; 34:187-194. [PMID: 31768720 PMCID: PMC7223952 DOI: 10.1007/s00540-019-02714-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/14/2019] [Indexed: 01/25/2023]
Abstract
Purpose The present case–control study was conducted to evaluate whether acute normovolemic hemodilution (ANH) can reduce the need for perioperative allogeneic blood transfusion (ABT) and affect the incidence of perioperative complications in free-flap reconstruction of the head and neck. Methods This single-center, retrospective, observational study included the perioperative data of 123 patients who underwent free-flap reconstruction of the head and neck following oncological surgery. Patients were divided into the following two groups according to whether they received ANH: ANH group and non-ANH group. We investigated whether ANH can reduce the need for perioperative ABT using propensity score-adjusted logistic regression analysis. Results Of the 123 patients, 113 patients were assessed; 57 patients were in the ANH group and 56 patients were in the non-ANH group. The rate [ANH group vs. non-ANH group, n (%): 2 (3.5%) vs. 23 (41.1%), p < 0.0001] and amount [median (IQR): 0 mL (0, 0) vs. 0 mL (0, 280), p < 0.0001] of ABT were significantly lower in the ANH group than in the non-ANH group. Propensity score-adjusted multivariate logistic regression analysis indicated that ANH use [odds ratio (OR): 0.040; 95% confidence interval (CI) 0.005, 0.320; p = 0.0024)] was one of the independent predictors of perioperative ABT. There were no significant differences in the incidences of post-operative complications between the two groups. Conclusion ANH use can reduce the need for perioperative ABT in patients undergoing free-flap reconstruction of the head and neck without increasing the incidence of post-operative complications.
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Which plasma biomarker may reflect severity of illness in ICU patients with systemic inflammation? Br J Anaesth 2019. [DOI: 10.1016/j.bja.2018.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Higher plasma leptin and lower C-peptide levels are associated with depression: A cross-sectional study. J Affect Disord 2019; 243:70-74. [PMID: 30236760 DOI: 10.1016/j.jad.2018.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/03/2018] [Accepted: 09/09/2018] [Indexed: 01/03/2023]
Abstract
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.
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Abstract
BACKGROUND The orexinergic (OXergic) system contributes to the defense system. It has also been reported that the degeneration of OXergic neurons occurs during sepsis. Thus, the decline of OXergic activity may contribute to impairment of the defense system in sepsis. In this study, we determined whether: (i) lipopolysaccharide (LPS) reduces the brain orexin A (OXA) content and (ii) the OXergic system contributes to survival from sepsis in rats. METHODS With approval of our protocol by our University Animal Ethics Committee, OX neuron-ablated (OX/ataxin-3 transgenic [OX/AT3 TG]) and wild-type Sprague-Dawley rats, weighing 250-350 g, were used. LPS (10 mg/kg) was administered intraperitonally to the wild-type rats (group SD, n = 26) and OX/AT3 TG rats (group TG, n = 14). Another 7 SD rats were included as a saline control (group C). Survival analysis was then performed over a period of 3 days. All surviving rats were decapitated and the brain OXA contents (from the cerebrocortex, hippocampus, hypothalamus, and pons) were quantified using ELISA kits. RESULTS In group SD, 61.5% rats survived, while in group TG, only 21.4% survived (p < 0.05). LPS significantly reduced OXA content (pg/mg of tissue) in group SD (2.92 ± 0.38) compared to in group C (4.10 ± 1.21) in the pons (p < 0.05). OXA content in group TG was substantially lower than in group C and group SD in all brain regions. CONCLUSIONS LPS significantly reduced OXA contents in the pons which contains the locus coeruleus to regulate sympathetic activity in the defense system.
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Anesthetic management of a patient with narcolepsy by combination of total intravenous and regional anesthesia: a case report. JA Clin Rep 2018; 3:37. [PMID: 29457081 PMCID: PMC5804620 DOI: 10.1186/s40981-017-0107-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/06/2017] [Indexed: 12/21/2022] Open
Abstract
Narcolepsy is a neurological disease characterized by excessive daytime sleepiness, cataplexy, and/or a sudden loss of muscle tone due to malfunction of the orexinergic system, which may cause delayed emergence from general anesthesia. We report a successful anesthetic management of 24-year-old female narcoleptic patient undergoing left anterior cruciate ligament reconstruction. Anesthesia was induced and maintained with total intravenous anesthesia (TIVA) using propofol and remifentanil. Ultrasound-guided left femoral nerve block was also performed with 0.375% ropivacaine 20 ml. Acetaminophen 1000 mg was intravenously administered as part of a multimodal analgesia. After the surgery, the trachea was extubated 9 min after termination of TIVA, and then, the patient correctly responded to verbal commands. The postoperative course was uneventful without any narcoleptic symptoms.
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Anesthetic management of a hydrocephalus patient with inclusion body myositis. JA Clin Rep 2017. [PMCID: PMC6967061 DOI: 10.1186/s40981-017-0129-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rebound hyperkalemia after cessation of ritodrine in a parturient undergoing cesarean section. JA Clin Rep 2017; 3:3. [PMID: 29492442 PMCID: PMC5813716 DOI: 10.1186/s40981-016-0071-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/13/2016] [Indexed: 11/25/2022] Open
Abstract
A 36-year-old parturient with a suspicion of placenta accreta under tocolytic therapy with ritodrine infusion underwent emergency cesarean section under general anesthesia with propofol, ketamine, and remifentanil because massive bleeding was anticipated. The ritodrine infusion was discontinued 1 h before cesarean section. The baby was delivered 6 min after induction of anesthesia. However, after the manual removal of the placenta from the uterus, the bleeding was massive and uncontrollable. We rapidly transfused crystalloid, colloid, and red blood cells through potassium removal filter. Hyperkalemia (5.8 mmol/L) was detected just before blood transfusion. One hour later, hemostasis was still difficult, and hyperkalemia was promoted (6.1 mmol/L). Thus, glucose insulin therapy started with intravenous furosemide to treat hyperkalemia. Gynecologists decided to induce the Bakri balloon tamponade for the treatment of postpartum hemorrhage. At the end of surgery, plasma potassium level also reduced to 5.5 mmol/L. In the ICU, the bleeding still continued, and then radiologists performed bilateral internal iliac artery embolization for full hemostasis. Postoperative plasma potassium level was stable and 3.3 mmol/L in the next morning. Although one of the common adverse reactions of ritodrine is hypokalemia, we should also beware of a rebound hyperkalemia after its cessation.
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Analysis of the essentiality of ROM2
genes in the pathogenic yeasts Candida glabrata
and Candida albicans
using temperature-sensitive mutants. J Appl Microbiol 2015; 118:851-63. [DOI: 10.1111/jam.12745] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/26/2014] [Accepted: 01/02/2015] [Indexed: 12/19/2022]
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[A case with hepatocellular carcinoma effectively treated by continuous hepatic arterial infusion of etoposide, epirubicin and CDDP]. Gan To Kagaku Ryoho 1992; 19:383-6. [PMID: 1311915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A 53-year-old man who suffered from advanced hepatocellular carcinoma (HCC) was treated with hepatic arterial infusion (HAI) of Etoposide, Epirubicin and CDDP. Treatment consisted of a continuous HAI of Epirubicin (50 mg/body, day 1.7), CDDP (75 mg/body, day 2.8) and Etoposide (80 mg/body, day 4-6). He had two series of infusions and was treated by transarterial embolization using CDDP powder (100 mg) added to lipiodol and aluminum stearate as suspension following HAI. The tumor regression rate was about 60% after HAI, but the remaining tumor seemed to be almost necrotic. AFP and PIVKA-II reached the normal range after TAE. We could not find lipiodol accumulated in tumor on CT carried out eight weeks after TAE. No recurrence has been noticed in the following 8 months. Toxicity was not so severe and was well tolerated.
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