Midoriko Higashi

Tranexamic acid (TXA) is a risk factor for perioperative seizures following cardiac surgery. However, its clinical diagnosis is difficult because these signs are masked by anesthetics and muscle relaxants. In this case, a direct temporal association between high-dose TXA administration and seizure onset was confirmed using intraoperative electroencephalography (EEG) and central venous oxygen saturation (ScvO ₂ ) changes.This case demonstrates that seizures can be triggered immediately after high-dose TXA administration and highlights the importance of integrated assessment of continuous EEG and ScvO ₂ for the early detection of subclinical seizures. This allows for prompt intervention and may lead to better neurological outcomes.

Background/Objectives: This study aimed to develop and evaluate an automated fluid infusion management system for preventing hypotension during general anesthesia. Methods: This study was a single-blind, randomized, non-inferiority, clinical trial. Seventy-nine patients undergoing surgery under general anesthesia were randomly assigned to either an automatic group or a manual group. In the automatic group, the infusion rate was automatically adjusted based on stroke volume (SV) and effective arterial elastance (Ea), whereas in the manual group, the attending anesthesiologist manually adjusted the infusion rate according to the Enhanced Recovery After Surgery (ERAS) protocol. The primary endpoint was the proportion of time during anesthesia that mean arterial pressure (Pm) was maintained at ≥65 mmHg. Secondary endpoints included the proportion of time the estimated stroke volume index (esSVI) was below the threshold, total fluid volume administered, total phenylephrine dose, urine output, blood loss, and average estimated stroke volume variation (esSVV). Results: The results demonstrated non-inferiority of the automatic group to the manual group in maintaining Pm ≥ 65 mmHg (automatic group: 82.0 ± 12.7%, manual group: 79.9 ± 15.7%; difference [automatic group−manual group]: 2.0 percentage points; one-sided 97.5% CI lower limit: −4.7%; non-inferiority margin: −5%). There were no significant differences between the groups in total fluid volume, phenylephrine dose, urine output, or blood loss. No severe adverse events or device-related adverse events were observed. Conclusions: The automated system maintained intraoperative blood pressure safely and effectively.

Purpose Plethysmography using the finger is affected by various clinical conditions, including sympathetic tone. This study aimed to evaluate whether pulse wave transit time (PWTT) calculated using ear plethysmography could be used as a substitute for finger PWTT. Methods In this prospective observational study, 50 patients underwent elective hepatectomy between December 2021 and April 2022. PWTT was simultaneously measured using finger and ear plethysmography. The primary outcome was the global agreement of all PWTT measurements. The secondary outcome was trending ability during hemodynamic changes. Results In total, 311 paired readings from 50 patients were collected. PWTT-ear was shorter than PWTT (68.1 ± 15.1 ms). For the percent change in PWTT from baseline (%ΔPWTT), linear regression analyses showed a strong correlation between %ΔPWTT-ear and %ΔPWTT (r = 0.85, P < 0.001). In Bland-Altman analyses, the bias between %ΔPWTT-ear and %ΔPWTT was − 0.04% and limits of agreement from − 0.17 to 0.17%, with a percentage error (2 standard deviation/mean %ΔPWTT) of 4.2%. The conductance rate of the two methods was 95.9% based on a four-quadrant plot analysis. The angular conductance rate was 98.9% with a radial limit of ± 25.3 based on a polar plot analysis. Conclusion PWTT-ear was shorter than PWTT, but the % change in PWTT-ear was similar to that in PWTT. PWTT measured using ear plethysmography can be used as a substitute for measuring changes in PWTT. Trial registration This study was registered in the UMIN-CTR Clinical Database (ID: UMIN000045950), https://center6.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000052326 on December 08, 2021.

BACKGROUND Postoperative acute liver failure, a complication following spine surgery, can cause delayed emergence from total intravenous anesthesia. Here, we report a case of acute severe postoperative liver failure following posterior spinal correction and fusion in a patient with congenital scoliosis. CASE REPORT A girl's congenital scoliosis worsened, and posterior spinal correction and fusion was scheduled. General anesthesia was induced with sevoflurane, fentanyl, target-controlled-infusion with propofol, and rocuronium. General anesthesia was maintained using target-controlled-infusion with propofol and remifentanil. The operation was completed with no remarkable complications. The operative time was 516 min and the anesthesia time was 641 min in the prone position. Emergence from anesthesia was poor, and it took 68 min to remove the tracheal tube after discontinuation of the anesthetic agents. The patient was drowsy and was transferred to her room in a general ward without reporting any pain, nausea, or dyspnea. On postoperative day 1, the results of laboratory investigations were suggestive of acute liver failure; contrast-enhanced computed tomography revealed a poorly enhanced area in the umbilical portion of the left liver lobe portal vein, indicating ischemic liver damage. Although no additional treatment was administered for acute liver failure, the patient recovered over time, and laboratory values normalized. No other postoperative complications were observed, and the patient was discharged on postoperative day 1. CONCLUSIONS Delayed emergence from general anesthesia may be due to acute liver failure following posterior spinal correction and fusion. There are several possible causes of postoperative liver failure, including anesthetics, prone position, and spinal surgery.

Lower-Leg Amputation Performed Under Regional Anesthesia in a Patient with Epidermolysis Bullosa: A Case Report - Article abstract #936722

Background: Although peripherally inserted central catheters (PICCs) have been widely used, they have not been frequently used in anesthesia practice. The central venous pressure measured via PICCs are reportedly as accurate as that measured via central venous catheters (CVCs), but the findings concerning rapid infusion are unclear. This study examined whether or not pressure-resistant PICCs could be used for rapid fluid infusion. Methods: The in-line pressure was measured in similar-sized double-lumen catheters—4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (20 and 13 cm)—at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion. Results: The pressure-resistant PICCs obtained a high flow rate similar to that of CVCs, but the in-line pressures increased in proportion to the flow rate and catheter length. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC. Conclusion: Pressure-resistant PICCs can be used for rapid fluid infusion.

Background Peripherally inserted central catheters (PICCs) have been widely used because of their low risk of mechanical complications associated with insertion compared with central venous catheters (CVCs). However, PICCs are not widely used for anesthetic management due to concerns regarding the measurement of central venous pressure (CVP) and rapid fluid infusion. The CVP measured via PICCs are reportedly as accurate as that measured via CVC, but the findings concerning rapid infusion are unclear. We therefore investigated the usefulness of a PICC as a rapid infusion route compared with a CVC. Methods The in-line pressure was measured in similar-sized double-lumen catheters - 4-Fr PICC (55, 45 and 35 cm) and 17-G CVC (13 and 20 cm) - at flow rates of saline decided using a roller pump system. We also examined the flow rate at an in-line pressure of 300 mmHg, which is the critical pressure at which hemolysis is considered to occur during blood transfusion. Results In-line pressures increased in proportion to the flow rate and catheter length in both the PICC and CVC. On comparing the 45-cm PICC and 20-cm CVC, the in-line pressures were higher in the PICC than in the CVC at a flow rate of ≤30 mL/min, although the opposite was true at a flow rate of ≥90 mL/min. Flow rates at an intra-circuit pressure of 300 mmHg were not significantly different between the 45-cm PICC and 20-cm CVC. Conclusion A PICC can be used for rapid fluid infusion and blood transfusion, just like a CVC.

Background: We aimed to evaluate the effect of third-generation hydroxyethyl starch (6% HES 130/0.4) on hemostasis and perioperative blood loss in patients undergoing off-pump coronary artery bypass (OPCAB) with continuation of preoperative aspirin. Methods: Forty-nine consecutive patients, who underwent OPCAB at a single institution between November 1, 2014 and March 31, 2016, were included. Coagulation tests, including thromboelastometry and clinical data of all patients, retrospectively were collected from anesthesia and medical records. Results: The total amount of intraoperative crystalloid and HES was 2057.5 ± 771.6 mL (N = 32) and 1090.6 ± 645.0 mL (N = 32), respectively. In the coagulation pathway, the change ratio of fibrinogen concentration, prothrombin time, and fibrinogen thromboelastometry-maximum clot firmness (FIBTEM-MCF) significantly correlated with HES (P < 0.001, P = 0.00131, and P < 0.001, respectively), but not with crystalloid. In the coagulation pathway concerning interaction with platelets, the change ratio of platelet count, extrinsic thromboelastometry-clotting formation time (EXTEM-CFT), and EXTEM-MCF significantly were correlated with HES (P < 0.001, P < 0.001, and P < 0.001, respectively), but not with crystalloid. At chest closure, the hematocrit decreased in a dose-dependent manner with HES (P < 0.001), but not with crystalloid administration. There was an association between the change ratio of hematocrit and EXTEM-MCF (P = 0.00122). However, intra-postoperative blood loss was not correlated with HES 130/0.4 or crystalloid administration. Conclusion: We found that 6% HES 130/0.4 prolonged coagulation testing in a dose-dependent manner due to hemodilution but did not increase blood loss in patients undergoing OPCAB with continuation of preoperative aspirin.

Background: Glutaric acidemia is a type of multiple acyl-coenzyme A dehydrogenase deficiency, an inborn error in fatty acid metabolism. In patients with glutaric acidemia, during the perioperative period, prolonged fasting, stress, and pain have been identified as risk factors for the induction of metabolic derangement. This report describes the surgical and anesthetic management of a patient with glutaric acidemia. Case presentation: A 56-year-old male patient with glutaric acidemia type 2 underwent a series of surgeries. During the initial off-pump coronary artery bypass surgery, the patient developed renal failure due to rhabdomyolysis upon receiving glucose at 2 mg/kg/min. However, in the second laparoscopic cholecystectomy, rhabdomyolysis was avoided by administering glucose at 4 mg/kg/min. Conclusions: To avoid catabolism in patients with glutaric acidemia, appropriate glucose administration is important, depending on the surgical risk.