JA Clinical Reports最新文献

Background: Venous air embolism (VAE) is a rare but potentially fatal complication in neurosurgery typically caused by injury to dura mater, especially venous sinuses, during craniotomy. We report two cases of VAE that occurred before dural incision.

Case presentation: Both patients underwent craniotomy under general anesthesia in a head-up position. Hemodynamic and respiratory deterioration occurred during or immediately after burr hole drilling with abnormal vital signs and transesophageal echocardiography findings, raising suspicion for VAE. Immediate management, including surgical field protection and cardiopulmonary support, stabilized the patients' conditions. The procedure was subsequently discontinued in case 1 and modified to limited resection in case 2. Postoperative computed tomography revealed intracranial venous air within the internal jugular vein, cavernous sinus, and diploic veins.

Conclusion: These cases highlight that VAE can occur even before dural incision. Vigilant intraoperative monitoring and prompt intervention are essential for preventing potentially fatal outcomes.

Background: Recovery of consciousness from general anesthesia with remimazolam, an ultrashort-acting benzodiazepine, occurs rapidly. However, patients after recovery of consciousness from general anesthesia with remimazolam often experience periods of amnesia. Remimazolam can be antagonized by flumazenil. Therefore, we investigated the effect of flumazenil on the recovery of memory following the recovery of consciousness from general anesthesia with remimazolam.

Methods: This single-center randomized controlled trial was conducted from November 2023 to July 2024. Forty-four patients undergoing breast surgery were enrolled. The patients received general anesthesia with remimazolam and remifentanil and were randomized to receive flumazenil after recovery of consciousness or not. The recovery of the memory was evaluated by showing an A4-size poster (illustration) to the patients and asking them to remember the poster every 1 h. Furthermore, the effect-site concentration of remimazolam was calculated using the Masui model.

Results: All 44 patients (22 with and 22 without flumazenil) were assessed. The percentage of patients who remembered the poster 1 h after regaining consciousness was significantly higher in the flumazenil group than in the no flumazenil group (95.5 vs 40.9%; p < 0.001). All patients could recall the poster within 2 h postoperatively. The mean effect-site concentration of remimazolam at the time of consciousness recovery was similar between the two groups (0.31 ± 0.08 µg/mL).

Conclusions: Flumazenil significantly accelerated the recovery of memory retention in patients who had recovered consciousness from general anesthesia with remimazolam. However, even without the administration of flumazenil, all patients successfully recovered their memory within 2 h after regaining consciousness.

Trial registration: This clinical trial was registered at the University Hospital Medical Information Network (UMIN) Center on November 01, 2023 (UMIN-CTR: UMIN000052659).

Background: Operational loss, defined as unanticipated financial deficits in intensive care unit (ICU) management, is challenging to predict yet critical for hospital sustainability. This study aimed to evaluate whether machine-learning models can predict financial loss events in postoperative ICU patients.

Methods: We conducted a retrospective analysis of postoperative patients admitted to the ICU at Tohoku University Hospital between April 2017 and March 2021. A total of 22 clinical and administrative variables collected within 24 h of ICU admission were used to develop machine-learning models. The outcome was defined as financial loss events, determined by a negative contribution margin below the break-even threshold of - 909 USD. The dataset was randomly split into training (70%) and test (30%) sets. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and accuracy.

Results: Among 6743 postoperative ICU patients, 425 (6.3%) experienced financial loss events. The random forest classifier demonstrated high predictive performance, with an AUC of 0.859 and accuracy of 0.785.

Conclusions: Machine-learning models may accurately predict financial loss events in postoperative ICU patients, potentially supporting efficient resource allocation and hospital financial planning.

Background: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant vascular disorder associated with hemorrhagic complications. In pregnant women with HHT, postpartum hemorrhage can be life-threatening and may necessitate hysterectomy.

Case presentation: A 36-year-old primigravida woman with HHT underwent emergency cesarean delivery due to nonreassuring fetal status. Following delivery, she developed massive uterine bleeding. Despite intrauterine balloon tamponade, hemorrhage persisted. Under the direction of the attending anesthesiologist and obstetrician, maternal resuscitation was initiated. Contrast-enhanced computed tomography revealed active extravasation from the right uterine artery. During emergent interventional radiology, angiography identified contrast extravasation from a hypertrophied spiral artery at the peripheral end of the right uterine artery, and embolization achieved initial hemostasis. She subsequently received intensive care under the supervision of the critical care team and ultimately recovered without hysterectomy.

Conclusions: Rapid multidisciplinary intervention for critical obstetric hemorrhage in a patient with HHT led to maternal survival and uterine preservation.

Background: Spinal extradural arachnoid cysts (SEACs) can cause persistent pain after surgery. Combining spinal cord stimulation (SCS) with structured exercise therapy may aid long-term pain modulation.

Case presentation: A teenage female with over two years of severe rib pain and bilateral leg pain/numbness was diagnosed with SEACs and underwent resection. A trial of SCS alleviated leg symptoms; rib pain persisted. After SCS implantation, leg symptoms resolved, and a gradual exercise progressed from pain-free stretching to low-intensity lower-limb exercises. Over 12 months, rib pain decreased and skeletal muscle mass increased. Pressure pain threshold and conditioned pain modulation improved, suggesting reduced sensitization and enhanced descending inhibition.

Conclusions: This case suggests that SCS may provide early pain relief, enabling initiation of structured exercise, associated with sustained pain reduction, improved pain modulation, and functional recovery. These observations suggest the SCS combined with exercise may be a useful option for selected patients with movement-limiting multifocal pain.

Background: Pulmonary artery catheter (PAC) entrapment is a rare but serious complication caused by inadvertent suturing to cardiac or vascular structures.

Case presentation: A 42-year-old man underwent minimally invasive mitral valve repair via right mini-thoracotomy. Thirty minutes after weaning from cardiopulmonary bypass (CPB), pulmonary artery pressure suddenly dropped, and the waveform became identical to that of central venous pressure. Two centimeters of PAC mobility, aspiration of blood from the balloon port, and blood accumulation in the monitor connector were noted. On postoperative day 1, resistance was encountered during catheter withdrawal at 7 cm, and chest radiography revealed abnormal catheter curvature. Reoperation under CPB confirmed PAC entrapment at the left atriotomy suture line, and the catheter was successfully removed.

Conclusions: In minimally invasive mitral valve repair, a left atriotomy approach might be associated with a risk of PAC entrapment, and the option of not inserting a PAC should always be considered.

Background: Pneumoperitoneum and Trendelenburg positioning are thought to increase pulmonary vascular resistance (PVR). In Fontan circulation, increased PVR is directly related to decreased ventricular preload and can result in circulatory failure.

Case presentation: A 23-year-old female patient with Fontan physiology was diagnosed with left paraovarian cyst torsion and underwent laparoscopic cystectomy. SpO₂ was 70% in room air. General anesthesia was induced with remimazolam, fentanyl, and rocuronium and maintained with remimazolam and remifentanil combined with an abdominal wall block. The difference between SpO₂ and central venous oxygen saturation (ScvO₂) increased during the induction of anesthesia and further increased with the initiation of pneumoperitoneum and Trendelenburg positioning but recovered at the completion of the surgery.

Conclusions: Patients with Fontan physiology and severe hypoxemia can tolerate short-term laparoscopic surgery in the Trendelenburg position under strict management. In these patients, monitoring ScvO₂ provides important circulatory information regarding the effects of pneumoperitoneum and Trendelenburg positioning.

Background: Acute abdominal pain is an uncommon manifestation of pheochromocytoma. Poor pain management may delay preoperative optimization of hemodynamics and intravascular blood volume. We report a case in which early epidural analgesia facilitated preoperative preparation for a laparoscopic adrenalectomy.

Case presentation: A female patient diagnosed with pheochromocytoma developed the sudden onset of severe left lower abdominal pain, hypertension, nausea, and vomiting. Pain treatment with acetaminophen and loxoprofen was insufficient, and opioids were avoided due to persistent nausea and constipation. Initiation of continuous thoracic epidural analgesia with 0.25% levobupivacaine resulted in rapid pain relief and improved gastrointestinal symptoms. Over a 9-day period, blood pressure and intravascular blood volume were optimized while epidural analgesia was continued. She underwent a successful adrenalectomy and was discharged without complications.

Conclusions: This case illustrates the potential utility of early epidural analgesia in the preoperative management of pheochromocytoma, particularly in patients with refractory abdominal pain and limited opioid tolerance.