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OBJECTIVE Carotid stenosis can lead to both cognitive impairment (CI) and ischemic stroke. Although carotid revascularization surgery, which includes carotid endarterectomy (CEA) and carotid artery stenting (CAS), can prevent future strokes, its effect on cognitive function is controversial. In this study, the authors examined resting-state functional connectivity (FC) in carotid stenosis patients with CI undergoing revascularization surgery, with a particular focus on the default mode network (DMN). METHODS Twenty-seven patients with carotid stenosis who were scheduled to undergo CEA or CAS between April 2016 and December 2020 were prospectively enrolled. A cognitive assessment, including the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Japanese version of the Montreal Cognitive Assessment (MoCA), as well as resting-state functional MRI, was performed 1 week preoperatively and 3 months postoperatively. For FC analysis, a seed was placed in the region associated with the DMN. The patients were divided into two groups according to the preoperative MoCA score: a normal cognition (NC) group (MoCA score ≥ 26) and a CI group (MoCA score < 26). The difference in cognitive function and FC between the NC and CI groups was investigated first, and then the change in cognitive function and FC after carotid revascularization was investigated in the CI group. RESULTS There were 11 and 16 patients in the NC and CI groups, respectively. The FC of the medial prefrontal cortex with the precuneus and that of the left lateral parietal cortex (LLP) with the right cerebellum were significantly lower in the CI group than in the NC group. In the CI group, significant improvements were found in MMSE (25.3 vs 26.8, p = 0.02), FAB (14.4 vs 15.6, p = 0.01), and MoCA scores (20.1 vs 23.9, p = 0.0001) after revascularization surgery. Significantly increased FC of the LLP with the right intracalcarine cortex, right lingual gyrus, and precuneus was observed after carotid revascularization. In addition, there was a significant positive correlation between the increased FC of the LLP with the precuneus and improvement in the MoCA score after carotid revascularization. CONCLUSIONS These findings suggest that carotid revascularization, including CEA and CAS, might improve cognitive function based on brain FC in the DMN in carotid stenosis patients with CI.

To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD).A single-center retrospective observational study.University teaching hospital.A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB).The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD:60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]),65 mmHg (OR = 1.72 [1.01-2.92]),70 mmHg (OR = 1.83 [1.03-3.26]), and75 mmHg (OR = 1.94 [1.02-3.69]).A longer cumulative duration of IOH with the threshold between60 and75 mmHg that occurred after CPB was independently associated with the risk of POD.

Objective To observe the perioperative free hemoglobin and haptoglobin levels and to assess their associations with the risk of postoperative acute kidney injury (pAKI) in adult patients undergoing valvular and aortic surgery requiring cardiopulmonary bypass (CPB). Design A single-center, prospective, observational study. Setting Public teaching hospital. Participants The study comprised 74 adult patients without chronic renal failure who underwent cardiovascular surgery requiring CPB from 2014 to 2020. Measurements and Main Results Perioperative free hemoglobin and haptoglobin levels during the study period were obtained from study participants. The primary outcome was pAKI defined by the Kidney Disease: Improving Global Outcomes criteria. Of the 74 patients in this study, pAKI occurred in 25 patients (33.8%). The free hemoglobin level began to increase after the initiation of CPB and reached a peak level at 30 minutes after weaning from CPB. It returned to the baseline level on postoperative day one. Haptoglobin levels were the highest after anesthesia induction and decreased continuously until postoperative day one. In the multivariate analysis, maximum free hemoglobin and minimum haptoglobin were associated independently with increased risk of pAKI (adjusted odds ratio 1.33 [95% confidence interval 1.12-1.58; p = 0.001] and 0.95 [95% confidence interval 0.91-1.00; p = 0.03], respectively). The free hemoglobin level began to have an independent association with pAKI at one hour after commencement of CPB, and the independent association disappeared at postoperative day one. Conclusions This study found that the perioperative increase of the free hemoglobin level and the decrease of the haptoglobin level had independent associations with the risk of pAKI.

BACKGROUND: Although there have been reports of Raeder’s syndrome developing after carotid artery dissection, to our knowledge, no case of Raeder’s syndrome occurring after carotid stenting has been reported. CASE REPORT: A 46-year-old man was urgently treated with a self-expanding stent for idiopathic right carotid artery dissection. However, the patient complained of moderate oppressive pain in the right orbit and forehead immediately after stent placement. Further examination revealed a right eye miosis and right ptosis. No anhidrosis was noted. A diagnosis of Raeder’s syndrome was made based on partial Horner’s syndrome and pain in the first branch of the trigeminal nerve. We noticed that he had hypertension and started antihypertensive medication. After starting the antihypertensive medication, his blood pressure stabilized, and his periorbital pain disappeared dramatically as his blood pressure fell. However, Horner’s symptoms (miosis and ipsilateral ptosis) were still present. CONCLUSION: We experienced a case of Raeder’s syndrome that occurred after stenting of the carotid artery. Neuralgia improved by treatment of hypertension. It should be noted that the paratrigeminal neuralgia of Raeder’s syndrome after carotid stenting can be caused by hypertension. KEY WORDS: Antihypertensive medication, Horner’s symptoms, Raeder’s syndrome, stenting of the carotid artery

Liberation from mechanical ventilation is of great importance owing to related complications from extended ventilation time. In this prospective multicenter study, we aimed to construct a versatile model for predicting extubation outcomes in critical care settings using obtainable physiological predictors. The study included patients who had been extubated after a successful 30 min spontaneous breathing trial (SBT). A multivariable logistic regression model was constructed to predict extubation outcomes (successful extubation without reintubation and uneventful extubation without reintubation or noninvasive respiratory support) using eight parameters: age, heart failure, respiratory disease, rapid shallow breathing index (RSBI), PaO2/FIO2, Glasgow Coma Scale score, fluid balance, and endotracheal suctioning episodes. Of 499 patients, 453 (90.8%) and 328 (65.7%) achieved successful and uneventful extubation, respectively. The areas under the curve for successful and uneventful extubation in the novel prediction model were 0.69 (95% confidence interval (CI), 0.62–0.77) and 0.70 (95% CI, 0.65–0.74), respectively, which were significantly higher than those in the conventional model solely using RSBI (0.58 (95% CI, 0.50–0.66) and 0.54 (95% CI, 0.49–0.60), p = 0.004 and

Signal regulatory protein α (SIRPα) is expressed predominantly on type 2 conventional dendritic cells (cDC2s) and macrophages. We previously showed that mice systemically lacking SIRPα were resistant to experimental autoimmune encephalomyelitis (EAE). Here, we showed that deletion of SIRPα in CD11c+ cells of mice (SirpaΔDC mice) also markedly ameliorated the development of EAE. The frequency of cDCs and migratory DCs (mDCs), as well as that of Th17 cells, were significantly reduced in draining lymph nodes of SirpaΔDC mice at the onset of EAE. In addition, we found the marked reduction in the number of Th17 cells and DCs in the CNS of SirpaΔDC mice at the peak of EAE. Whereas inducible systemic ablation of SIRPα before the induction of EAE prevented disease development, that after EAE onset did not ameliorate the clinical signs of disease. We also found that EAE development was partially attenuated in mice with CD11c+ cell-specific ablation of CD47, a ligand of SIRPα. Collectively, our results suggest that SIRPα expressed on CD11c+ cells, such as cDC2s and mDCs, is indispensable for the development of EAE, being required for the priming of self-reactive Th17 cells in the periphery as well as for the inflammation in the CNS.

Purpose Patients undergoing gynecological surgery are considered to be a high-risk cohort for postoperative nausea and vomiting (PONV). The purpose of this study was to assess the association of intraoperative end-tidal carbon dioxide (EtCO2) with risk of PONV in patients underwent gynecological open surgery. Methods In this single-center retrospective observational study, we included patients aged 20–60 years who underwent elective gynecological open surgery. We obtained data for the incidence of PONV within 24 h after operation. We collected EtCO2 every minute during the operation, and determined the lowest value of EtCO2. We compared the lowest EtCO2 between patients with and without PONV. Multivariate logistic regression analysis was performed to assess the independent association of EtCO2 with the risk of PONV. Results A total of 146 patients were included in the current study. There were 81 patients with PONV within 24 h after the operation. The median lowest value of EtCO2 in patients with PONV was significantly lower than that in patients without PONV (31 vs 33 mmHg, p = 0.02). In the multivariate logistic regression model, we found that lowest EtCO2 ≤ 31 mmHg was independently associated with increase in the risk of PONV (adjusted odds ratio = 3.37, p = 0.02). Conclusion In this retrospective observational study, low intraoperative EtCO2 was shown to be independently associated with increased risk of PONV. However, this result may be skewed by uncollected information including previous PONV, motion sickness or other unknown bias, so future studies should be conducted to refute or confirm our findings.

Purpose To assess the impact of intravenous isotonic and hypotonic maintenance fluid on the risk of delirium in adult postoperative patients, we conducted retrospective before-after study in a tertiary teaching hospital. Methods We examined all adult patients admitted ICU after an elective operation for head and neck cancer, or esophageal cancer from February 2014 to January 2017. From February 2014 to July 2015, patients were administered hypotonic fluid (sodium; 35 mmol/L) as the National Institute for Health and Care Excellence (NICE) have recommended. From August 2015 to January 2017, patients were administered isotonic fluid (sodium; 140 mmol/L). We defined the incidence of delirium as the primary outcome. The delirium was defined as the Intensive Care Delirium Screening Checklist during the ICU stay ≥ 4. A propensity score-matched model was used to adjust confounders. Results As postoperative intravenous maintenance fluid, hypotonic fluid was administered to 119 patients and isotonic fluid was administered to 92 patients. Among those total cohorts, the incidence of postoperative delirium in the hypotonic group was 21.8%, which was significantly higher than that (9.8%) in the isotonic group (p = 0.019). After propensity score matching, we selected 77 patients in each group. The incidence of delirium during the ICU stay in the hypotonic group was 26.0%, which was significantly higher than the incidence of 11.7% in the isotonic group (p = 0.023). Conclusions In this study, the use of postoperative hypotonic maintenance fluid was associated with a higher risk of postoperative delirium than that when isotonic maintenance fluid was used.

Upregulation of N-type Ca2+ channel dependent subunits increases functional connections and synchronization for pain formation., Sustained neuropathic pain from injury or inflammation remains a major burden for society. Rodent pain models have informed some cellular mechanisms increasing neuronal excitability within the spinal cord and primary somatosensory cortex (S1), but how activity patterns within these circuits change during pain remains unclear. We have applied multiphoton in vivo imaging and holographic stimulation to examine single S1 neuron activity patterns and connectivity during sustained pain. Following pain induction, there is an increase in synchronized neuronal activity and connectivity within S1, indicating the formation of pain circuits. Artificially increasing neuronal activity and synchrony using DREADDs reduced pain thresholds. The expression of N-type voltage-dependent Ca2+ channel subunits in S1 was increased after pain induction, and locally blocking these channels reduced both the synchrony and allodynia associated with inflammatory pain. Targeting these S1 pain circuits, via inhibiting N-type Ca2+ channels or other approaches, may provide ways to reduce inflammatory pain.

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) causes severe pain that cannot be controlled well by common analgesic drugs. This is a first case report of intractable mandibular pain due to ARONJ that was eliminated by a continuous mandibular nerve block. A 72-year-old woman with osteoporosis had been administered bisphosphonate. One year after extraction of her tooth, she was diagnosed as having ARONJ. Jaw pain was so severe that she was unable to open her mouth and eat. We performed a continuous mandibular nerve block through an indwelling catheter with levobupivacaine for pain management. After the procedure, her rest pain was markedly improved, and the pain induced by opening her mouth disappeared. We conclude that a continuous mandibular nerve block may be helpful in the management of ARONJ.

BACKGROUND: The risk of surgical site infection has been reported to be higher in patients with poorly controlled diabetes. Since chronic hyperglycemia impairs neutrophil functions, preoperative glycemic control may restore neutrophil function. However, long-term insulin therapy may lead to a delay in surgery, which may be a problem, especially in cancer surgery. It is therefore unfortunate that there have been few studies in which the optimal duration of perioperative glycemic control for diabetes with chronic hyperglycemia was investigated. Therefore, we investigated the effects of preoperative long-term insulin therapy and short-term insulin therapy on perioperative neutrophil functions in diabetic mice with chronic hyperglycemia. METHODS: Five-week-old male C57BL/6J mice were divided into four groups (Untreated (Diabetes Mellitus: DM), Short-term (DM), Long-term (DM), and Non-diabetic groups). Diabetes was established by administrating repeated low-dose streptozotocin. The Short-term (DM)group received insulin therapy for 6 hours before the operation and the Long-term (DM)group received insulin therapy for 5 days before the operation. The Untreated (DM) group and the Non-diabetic group did not receive insulin therapy. At 14 weeks of age, abdominal surgery with intestinal manipulation was performed in all four groups. We carried out a phagocytosis assay with fluorescent microspheres and a reactive oxygen species (ROS) production assay with DCFH-DA (2’,7’-dichlorodihydrofluorescein diacetate) before and 24 hours after the operation using FACSVerse™ with BD FACSuite™ software. RESULTS: Blood glucose was lowered by insulin therapy in the Short-term (DM) and Long-term (DM) groups before the operation. Neutrophilic phagocytosis activities before and after the operation were significantly restored in the Long-term (DM) group compared with those in the Untreated (DM) group (before: p = 0.0008, after: p = 0.0005). However, they were not significantly restored in the Short-term (DM) group. Neutrophilic ROS production activities before and after the operation were not restored in either the Short-term (DM) group or Long-term (DM) group. CONCLUSIONS: Preoperative and postoperative phagocytosis activities are restored by insulin therapy for 5 days before the operation but not by insulin therapy for 6 hours before the operation.

BACKGROUND: The risk of surgical site infection has been reported to be higher in patients with poorly controlled diabetes. Since chronic hyperglycemia impairs neutrophil functions, preoperative glycemic control may restore neutrophil function. However, long-term insulin therapy may lead to a delay in surgery, which may be a problem especially in cancer surgery. It is therefore unfortunate that there was no study to investigate the optimal duration of perioperative glycemic control for diabetes with chronic hyperglycemia. Therefore, we investigated the effects of preoperative long-term insulin therapy and short-term insulin therapy on perioperative neutrophil functions in diabetic mice with chronic hyperglycemia. METHODS: Five-week-old mice were administered streptozotocin to induce diabetes. We divided the diabetic mice into three groups: a group of mice with untreated diabetes (untreated group), a group of mice that received insulin therapy for 6 hours before surgery (short-term group) and a group of mice that received insulin therapy for 5 days before surgery (long-term group). A group of non-diabetic mice were used as a control group. At 14 weeks of age, abdominal surgery with intestinal manipulation was performed in all four groups. We carried out a phagocytosis assay by fluorescent microspheres and a reactive oxygen species (ROS) production assay by DCFH-DA (2’,7’-dichlorodihydrofluorescin diacetate) before and after surgery using FACSVerse™ with BD FACSuite™ software. Phagocytosis rate (%) was calculated by dividing the number of phagocytic beads by neutrophil count. Fluorescence from DCF (dichlorofluorescein) in the neutrophils was measured and expressed as mean fluorescence intensity (MFI). RESULTS: Blood glucose was lowered by insulin therapy in the short-term and long-term groups before the operation. Neutrophilic phagocytosis activities before and after the operation were significantly restored in the long-term group compared with those in the untreated group (before: p = 0.0008, after: p = 0.0005). However, they were not significantly restored in the short-term group. Neutrophilic ROS production activities before and after the operation were not restored in either the short-term group or long-term group. CONCLUSIONS: Preoperative and postoperative phagocytosis activities are restored by insulin therapy for 5 days before the operation but not by insulin therapy for 6 hours before the operation.

Purpose To apply continuous glucose monitoring (CGM) and determine the mean amplitude of glycemic excursions (MAGE) in septic patients and to assess the associations of MAGE with outcomes and oxidative stress. Materials and methods This study was conducted in adult septic patients expected to require intensive care for >48 h. We continuously measured blood glucose level for the first 48 h in the ICU using FreeStyle Libre®. MAGE was calculated using glycemic information obtained by CGM during the study period of 48 h. The primary outcome was 90-day all-cause mortality. The secondary outcomes were 90-day ICU-free days and the concentration of urinary 8-isoprostaglandinF2α measured 48 h after commencement of the study as a surrogate of oxidative stress. Results Forty patients were included in this study. Median of MAGE was higher in non-survivors than in survivors: 68.8 (IQR;39.7–97.2) vs. 39.3 (IQR;19.9–53.3), p = 0.02. In multivariate analysis, MAGE was independently associated with 90-day all-cause mortality rate (p = 0.02), urinary 8-isoprostaglandinF2α level (p = 0.03) and 90-day ICU-free survival days (p = 0.03). Conclusions In the current study, MAGE for the first 48 h of treatment that was obtained by using CGM was associated with 90-day all-cause mortality, 90-day ICU-free days and urinary 8-isoprostaglandinF2α level in septic patients.

We managed general anesthesia for transcatheter aortic valve replacement (TAVR) under elective extracorporeal membrane oxygenation (ECMO) in a patient with aortic valve stenosis (AS) complicated with acute decompensated heart failure. The patient was an 87-year-old woman with acute heart failure due to severe AS who had been hospitalized. However, her low cardiac output did not improve, and weaned her off catecholamines was difficult, so semi-urgent TAVR was performed. Due to her acute decompensated heart failure complicated by low-left ventricular function, we decided electively to use ECMO for transfemoral TAVR to prevent hemodynamic collapse during induction of anesthesia and surgery, enabling the safe perioperative management of this patient under general anesthesia.

Purpose To observe arterial oxygen in relation to fraction of inspired oxygen (FIO2) during mechanical ventilation (MV). Materials and methods In this multicenter prospective observational study, we included adult patients required MV for >48 h during the period from March to May 2015. We obtained FIO2, PaO2 and SaO2 from commencement of MV until the 7th day of MV in the ICU. Results We included 454 patients from 28 ICUs in this study. The median APACHE II score was 22. Median values of FIO2, PaO2 and SaO2 were 0.40, 96 mm Hg and 98%. After day two, patients spent most of their time with a FIO2 between 0.3 and 0.49 with median PaO2 of approximately 90 mm Hg and SaO2 of 97%. PaO2 was ≥100 mm Hg during 47.2% of the study period and was ≥130 mm Hg during 18.4% of the study period. FIO2 was more likely decreased when PaO2 was ≥130 mm Hg or SaO2 was ≥99% with a FIO2 of 0.5 or greater. When FIO2 was Conclusions In our multicenter prospective study, we found that hyperoxemia was common and that hyperoxemia was not corrected.

Background: Hyperbilirubinemia is a common postoperative complication. Elevated direct bilirubin (D-Bil) and indirect bilirubin (I-Bil) levels are related to different pathophysiologies; therefore, their associations with outcomes also differ. However, there have been few comparative studies of such associations in postoperative patients. Methods: This retrospective study compared the associations of postoperative D-Bil and I-Bil with outcomes. We included adult patients requiring postoperative intensive care for more than 48 hours between 2008 and 2013, except those undergoing liver operations. The number of patients was determined using a power calculation. D-Bil and I-Bil measurements were obtained on postoperative days (POD) 1 and 2. The primary outcome was defined as hospital mortality, with the number of ICU-free survival days (IFSD) at POD 28 as the secondary outcome. Results: The study population consisted of 1,903 patients with a mortality rate of 2.2%. D-Bil at POD 1 was significantly higher in non-survivors than survivors (P = 0.001), but I-Bil at POD 1 showed no such relation (P = 0.209). Multivariate logistic analysis indicated that higher postoperative D-Bil was independently associated with increased postoperative mortality (POD 1: adjusted odds ratio [OR] = 2.32, P < 0.001; POD 2: adjusted OR = 1.95, P < 0.001), but I-Bil showed no such relation (POD 1: P = 0.913; POD 2: P = 0.209). Increased D-Bil was independently associated with decreased IFSD at POD 28 (POD 1: adjusted coefficient = -1.54, P < 0.001; POD 2: -1.84, P < 0.001). In contrast, increased I-Bil at POD 1 was independently associated with increased IFSD at POD 28 (POD 1: adjusted coefficient = +0.39, P = 0.021; POD 2: +0.33, P = 0.080). Conclusions: D-Bil indices have a higher capability than I-Bil for predicting poorer outcomes in critically ill postoperative patients.

Background Derangement of serum sodium (Na) concentration is common and associated with adverse outcomes in postoperative patients. Therefore, accuracy of Na measurements should be relevant. Several studies had suggested that Na concentration measured by using central laboratory machine had been lower than the actual Na concentration in patients with hyper-proteinemia. Although hypo-proteinemia is common in postoperative patients, validation of Na measurements in this cohort is still poor. Methods In this retrospective study, we included patients who underwent an elective operation for esophageal cancer or for head and neck cancer and who required postoperative intensive care for >72 h. We obtained Na concentrations using indirect (blood central laboratory test using serum) and direct method (arterial blood gas analyzer using whole blood) simultaneously. We assess the difference of these paired Na concentrations, and determined its association with serum protein levels. Results The average Na concentrations measured by the two methods were significantly different (indirect:139.0 mmol/L, direct:137.2 mmol/L, p 145 mmol/L) indicated by the two methods were significantly different (hyponatremia; indirect:11.4%, direct:22.0%, p Conclusion The results suggest that the derangement of Na concentration might be underestimated when only one method is used for measurement of Na concentration in postoperative patients with hypo-proteinemia.

Hyperglycemia is commonly observed in critical illness. A landmark large randomized controlled trial (RCT) reported that the incidence of hyperglycemia (blood glucose concentration > 108 mg/dl) was as high as 97.2% in critically ill patients. During the past two decades, a number of RCTs and several meta-analyses and network meta-analyses have been conducted to determine the optimal target for acute glycemic control. The results of those studies suggest that serum glucose concentration would be better to be maintained between 144 and 180 mg/dl. Although there have been studies showing an association of hypoglycemia with worsened clinical outcomes, a causal link has yet to be confirmed. Nonetheless, some researchers are of the view that the data suggest even mild hypoglycemia should be avoided in critically ill patients. Since acutely ill patients who receive insulin infusion are at a higher risk of hypoglycemia, a reliable devices for measuring blood glucose concentrations, such as an arterial blood gas analyzer, should be used frequently. Acute glycemic control in patients with premorbid hyperglycemia is a novel issue. Available literature suggests that blood glucose concentrations considered to be desirable and/or safe in non-diabetic critically ill patients might not be desirable in patients with diabetes. Moreover, the optimal target for acute blood glucose control may be higher in critically ill patients with premorbid hyperglycemia. Further study is required to assess optimal blood glucose control in acutely ill patients with premorbid hyperglycemia.

Although spinal cord stimulation (SCS) is a useful treatment for chronic intractable pain, the optimal method of stimulation has not yet been established. In this prospective, crossover study, we compared the efficacy of using a constant current (CC) system with that of a constant voltage (CV) system for temporal SCS. Twenty patients were enrolled and divided into two groups. For 10 patients, a CV system was applied on Days 1-5, followed by the use of a CC system on Days 6-10. For the other 10 patients, a CC system was applied for the first five days, followed by a CV system for the subsequent five days. We evaluated the alteration of pain intensity using a visual analogue scale (VAS), the area of stimulation, the stability of effect, and patient satisfaction regarding treatment. The pain scores decreased significantly after the start of the SCS. There was no significant difference in the change in VAS between the two systems. The stimulation method used for temporal SCS did not affect the reduction of pain intensity. Patients felt a wider stimulation area by the CC system compared to the CV system.

Very long-chain acyl-coenzyme A dehydrogenase deficiency (VLCADD, OMIM 201475) is a congenital fatty acid oxidation disorder. Individuals with VLCADD should avoid catabolic states, including strenuous exercise and long-term fasting; however, such conditions are required when undergoing surgery. The perioperative management of VLCADD in infants has rarely been reported and details regarding the transition of serum biomarkers reflecting catabolic status have not been disclosed. Herein, we present the perioperative clinical and biological data of cryptorchidism in a 1.5-year-old boy with VLCADD. The patient was diagnosed through newborn screening and his clinical course was very stable. Genetic testing of ACADVL revealed compound heterozygous variants c.506 T > C (p.Met169Thr) and c.606-609delC (p.L216*). The enzyme activity of the patient with VLCAD was only 20% compared to that of healthy control. Left orchiopexy for the pediatric cryptorchidism was planned and performed at 1 and a half year of age. Induction anesthesia involved thiopental, fentanyl and rocuronium. The glucose infusion rate was maintained above 6.6 mg/kg/min starting the day before surgery until the operation was completed. Anesthesia was maintained with sevoflurane at approximately 2%. The serum concentration of tetradecenoylcarnitine were stable during the operation, ranging between 0.08 and 0.19 μM (cutoff, Highlights • Catabolic biomarker status details during surgery in infants with VLCADD is lacking. • We performed uneventful surgical intervention in a 1.5-year-old patient with VLCADD. • Serum levels of tetradecenoyl carnitine remained stable during the operation. • Serum biomarkers creatine kinase, 3-hydroxybutyrate, and free fatty acid remained similarly unchanged. • These findings will be beneficial in the management of VLCADD.

The purpose of this study was to compare the incidences of hyponatremia in adult postoperative critically ill patients receiving isotonic and hypotonic maintenance fluids. Methods In this single-center retrospective before/after observational study, we included patients who had undergone an elective operation for esophageal cancer or for head and neck cancer and who received postoperative intensive care for > 48 h from August 2014 to July 2016. In those patients, sodium-poor solution (35 mmol/L of sodium; Na-35) had been administered as maintenance fluid until July 2015. From August 2015, the protocol for postoperative maintenance fluid was revised to the use of isotonic fluid (140 mmol/L of sodium; Na-140). The primary outcome was the incidence of hyponatremia (< 135 mmol/L) until the morning of postoperative day (POD) 2. Results We included 179 patients (Na-35: 87 patients, Na-140: 92 patients) in the current study. The mean volume of fluid received from ICU admission to POD 2 was not significantly different between the two groups (3291 vs 3337 mL, p = 0.84). The incidence of postoperative hyponatremia was 16.3% (15/92) in the Na-140 cohort, which was significantly lower than that of 52.9% (46/87) in the Na-35 group (odds ratio = 0.17, 95% confidence interval 0.09–0.35, p < 0.001]. The incidences of hypernatremia, defined as serum sodium concentration > 145 mmol/L, were not significantly different between the two groups. Conclusion In this study, the use of intravenous maintenance fluid with 35 mmol/L of sodium was significantly associated with an increased risk of hyponatremia compared to that with 140 mmol/L of sodium in adult postoperative critically ill patients.

Objective To determine the effects of milrinone on short-term mortality in cardiac surgery patients with focus on the presence or absence of heterogeneity of the effect. Design A systematic review and meta-analysis. Setting and Participants Five hundred thirty-seven adult cardiac surgery patients from 12 RCTs. Interventions Milrinone administration. Measurements and Main Results The authors conducted a systematic Medline and Pubmed search to assess the effect of milrinone on short-term mortality in adult cardiac surgery patients. Subanalysis was performed according to the timing for commencement of milrinone administration and the type of comparators. The primary outcome was any short-term mortality. Overall analysis showed no difference in mortality rates in patients who received milrinone and patients who received comparators (odds ratio = 1.25, 95% CI 0.45-3.51, p = 0.67). In subanalysis for the timing to commence milrinone administration and the type of comparators, odds ratio for mortality varied from 0.19 (placebo as control drug, start of administration after cardiopulmonary bypass) to 2.58 (levosimendan as control drug, start of administration after cardiopulmonary bypass). Conclusions Among RCTs to assess the effect of milrinone administration in adult cardiac surgery patients, there are wide variations of the odds ratios of administration of milrinone for short-term mortality according to the comparators and the timing of administration. This fact may suggest that a simple pooling meta-analysis is not applicable for assessing the risk and benefit of milrinone administration in an adult cardiac surgery cohort.

Background In these days, the occurrence of neuropsychological complications during perioperative period has become the subject of discussion. Diabetes is indicated as one of the metabolic risk factors. Although the number of patients with diabetes mellitus (DM) has been increasing, the pathophysiology of postoperative neuropsychological dysfunction in DM patient is still unclear. Recently, a deficiency of neurotransmitters, such as monoamines, was reported to be associated with mental disorders. Therefore, we investigated the effects of surgical stress on behavioral activity and the hippocampal noradrenaline (NA) level in type 2 diabetes mellitus model (T2DM) mice.Methods Eighty-four 6-week-old male C57BL/6J mice were divided into four groups (control, surgery control, T2DM, and surgery T2DM groups). T2DM mice were established by feeding a high fat diet (HFD) for 8 weeks. At 14 weeks of age, fifteen mice in every group underwent a series of behavioral tests including an open field (OF) test, a novel objective recognition (NOR) test and a light-dark box (LD) test. In the surgery groups, open abdominal surgery with manipulation of intestine was performed 24 hours before the behavioral tests as a surgical stress. Hippocampal NA level was examined in six mice in each group by high-performance liquid chromatography. The data were analyzed by Mann-Whitney U test and P values less than 0.05 were considered significant.Results The T2DM group showed significantly increased explorative activity in the NOR test (P = 0.0016) and significantly increased transition in the LD test (P = 0.043) compared with those in the control group before surgery. In T2DM mice, surgical stress resulted in decreased total distance in the OF test, decreased explorative activity in the NOR test, and decreased transition in the LD test (OF: P = 0.015, NOR: P = 0.009, LD: P = 0.007) and decreased hippocampal NA (P = 0.015), although they were not revealed in control mice.Conclusion T2DM mice by feeding a HFD showed increased behavioral activities, and surgical stress in T2DM mice caused postoperative hypoactivity and reduction of hippocampal NA level.

We report a case of delayed respiratory depression due to accidental subcutaneous opioid infusion. A healthy 33-year-old woman underwent orthopedic surgery under general anesthesia. Before the end of the operation, it was noticed that a part of the opioid infusion had been administered subcutaneously. About 15 min after tracheal extubation, the patient developed respiratory depression and loss of consciousness. The patient recovered with the use of jaw lift together with bag-valve-mask ventilation. We believe that accidental subcutaneous opioid accumulation may have caused the respiratory depression.

Purpose Nafamostat mesilate (NM) can be used as a regional anticoagulant for continuous renal replacement therapy (CRRT). The primary aim of this study was to assess the association of the use of NM with risk of bleeding complications and compare it with the use of unfractionated heparin (UFH). Methods We conducted a single-center retrospective observational study. We included adult patients who required CRRT in our intensive care unit from 2011 to 2013. The primary outcome was the risk of bleeding complications during CRRT and the secondary outcome was filter life for the first filter of CRRT. Results We included 101 patients (76 with NM, 25 with UFH). Among the 101 patients, use of NM tended to be associated with lower risk of bleeding complications (6.6% vs. 16%; odds ratio, 0.37; p = 0.16). Propensity score matching generated 30 patients with NM and 15 patients with UFH with well-balanced baseline characteristics. Among the propensity score-matched cohorts, use of NM was significantly associated with decreased risk of bleeding complications (3.3% vs. 27%; odds ratio, 0.09; p = 0.04). In multivariate logistic analysis using the inverse probability of treatment weighting for sensitive analysis, the use of NM was independently associated with reduced risk of bleeding complications (p = 0.02). The median filter life was not significantly different for patients with NM and patients with UFH (25.5 hours vs. 30.5 hours, p = 0.16). Conclusions In our retrospective analysis, the use of NM as an anticoagulant during CRRT was associated with decreased incidence of bleeding complications compared with the use of UFH.

We report a successful case of fluoroscopic percutaneous retrocrural coeliac plexus neurolysis (PRCPN) for pancreatic cancer pain refractory to endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN). A 55-year-old man with upper abdominal pain due to end-stage pancreatic cancer underwent EUS-CPN. Although CT revealed distribution of the contrast medium with neurolytic agent around the left and cephalic sides of the coeliac artery, the pain did not improve and became even more severe. PRCPN was performed, resulting in the drastic improvement of pain immediately. PRCPN should be considered when EUS-CPN is not effective.

Background There has been much discussion recently about the occurrence of neuropsychological complications during the perioperative period. Diabetes is known to be one of the metabolic risk factors. Although the number of patients with diabetes mellitus (DM) has been increasing, the pathophysiology of postoperative neuropsychological dysfunction in DM patients is still unclear. Recently, a deficiency of neurotransmitters, such as monoamines, was reported to be associated with mental disorders. Therefore, we investigated the effects of surgical stress on behavioral activity and hippocampal noradrenaline (NA) level in type 2 diabetes mellitus model (T2DM) mice. Methods Eighty-four 6-week-old male C57BL/6J mice were divided into four groups (non-diabetes, non-diabetes with surgery, T2DM, and T2DM with surgery groups). T2DM mice were established by feeding a high-fat diet (HFD) for 8 weeks. At 14 weeks of age, fifteen mice in each group underwent a series of behavioral tests including an open field (OF) test, a novel object recognition (NOR) test and a light–dark (LD) test. In the surgery groups, open abdominal surgery with manipulation of the intestine was performed 24 h before the behavioral tests as a surgical stress. Hippocampal noradrenaline (NA) concentration was examined in six mice in each group by high-performance liquid chromatography. The data were analyzed by the Mann–Whitney U test, and p values less than 0.05 were considered significant. Results The T2DM group showed significantly increased explorative activity in the NOR test (P = 0.0016) and significantly increased frequency of transition in the LD test (P = 0.043) compared with those in the non-diabetic group before surgery. In T2DM mice, surgical stress resulted in decreased total distance in the OF test, decreased explorative activity in the NOR test, and decreased frequency of transition in the LD test (OF: P = 0.015, NOR: P = 0.009, LD: P = 0.007) and decreased hippocampal NA (P = 0.015), but such differences were not observed in the non-diabetic mice. Conclusions Mice with T2DM induced by feeding an HFD showed increased behavioral activities, and surgical stress in T2DM mice caused postoperative hypoactivity and reduction of the hippocampal NA level.