[A Suspected Case of Hemorrhagic Hereditary Telangiectasia Presented with Cerebral Hemorrhage in Infancy]

Hereditary hemorrhagic telangiectasia (HHT) is characterized by telangiectasias in multiple organs. We experienced an infant with cerebral hemorrhaging and suspected HHT based on his family history of HHT. Computed tomography angiography confirmed a cerebral arteriovenous fistula. The onset of cerebral arteriovenous fistulas associated with HHT is relatively early, and the incidence of bleeding is relatively common. When HHT is suspected based on a family history, early imaging screening is recommended to improve the neurological prognosis, even in asymptomatic cases. (Received April 7, 2020; Accepted May 7, 2020; Published August 1, 2020).

Feasibility of total intravenous anesthesia by cardiologists with the support of anesthesiologists during catheter ablation of atrial fibrillation

BACKGROUND

The optimal methodology for sedation and anesthesia during atrial fibrillation (AF) ablation has not been well established. We assessed the feasibility of total intravenous anesthesia (TIVA) by cardiologists with support from anesthesiologists during AF ablation and quality of pulmonary vein isolation (PVI) and single procedure success rate at 12 months.

METHODS

TIVA was performed by cardiologists using IV propofol and fentanyl under controlled ventilation via i-gel™ without neuromuscular blocking drugs in 160 consecutive patients (80 nonparoxysmal) with no anticipated difficult airway or other severe diseases. Anesthesiologists were requested to be on standby during the procedure. The incidence of anesthesia-associated complications and ablation-associated complications were assessed. To evaluate the quality of PVI, the prevalence of acute adenosine triphosphate (ATP)-provoked PV reconnections and late PV reconnections among those requiring a redo procedure was analyzed.

RESULTS

TIVA was successfully completed in 152 patients (95%). In five (3%), we requested help from anesthesiologists, and in three (2%), TIVA was abandoned. No major anesthesia-associated complications were observed. Ablation-associated complications were observed in seven patients (4%). ATP provocation test was performed in 141 patients, and no acute PV reconnections were observed in 134 (95%). Success rates at 12 months were 85% of patients off antiarrhythmic drugs. Twenty-one of 24 patients with recurrence underwent a redo session, and 18 (86%) had no PV reconnections.

CONCLUSIONS

TIVA by cardiologists with support from anesthesiologists during AF ablation may be feasible. The success rate at 12 months was high, and prevalence of acute and late PV reconnection was very low.

Necrotizing fasciitis and myonecrosis "synergistic necrotizing cellulitis" caused by Bacillus cereus

Our patient was a 37-year-old man with diabetes mellitus and hepatopathy as underlying diseases. Swelling, erythema and pain appeared in the left upper limb on the day before the initial examination. On examination, diffuse purpura was noted on the left upper limb, and, as it rapidly extended to the left upper trunk, emergency surgery was performed. Intraoperatively, gas-producing necrosis was observed not only in subcutaneous tissues but also from the fascia to muscle tissues, and the condition resembled clostridial gas gangrene. However, as the culturing of samples from the lesion yielded Bacillus cereus, a diagnosis of necrotizing fasciitis and myonecrosis (synergistic necrotizing cellulitis) due to B. cereus was made. While the patient developed a serious condition due to sepsis and disseminated intravascular coagulation, he could be saved by early debridement and intensive treatment with an appropriate selection of antibiotics.

Sivelestat relaxes porcine coronary artery via inhibition of Ca2+ sensitization induced by a receptor agonist

Sivelestat sodium hydrate (sivelestat) is a novel synthetic drug and specific inhibitor of neutrophil elastase that has been approved in Japan as a treatment for acute lung injury associated with systemic inflammatory response syndrome. There are no reports on the effects of sivelestat on the contractile regulation of vascular smooth muscle. The purpose of the present study was to assess the effects of sivelestat on porcine coronary artery. Sivelestat induced concentration-dependent (3 x 10 to 3 x 10 M) vasorelaxation in U46619 (100 nM)-precontracted porcine coronary artery with or without endothelium. Simultaneous measurements of tension and the cytosolic Ca concentration ([Ca]i) revealed that sivelestat shifted the [Ca]i-tension curve to the right and downward during stimulation with 118 mM K and 100 nM U46619. In beta-escin-permeabilized arterial strips, sivelestat abolished GTP plus U46619-induced contractions at constant [Ca]i, whereas it had no effect on Ca-induced contractions. Thus, sivelestat relaxes porcine coronary artery smooth muscle via the selective inhibition of Ca sensitization induced by a receptor agonist, without affecting Ca-induced contraction.

Survival case of Vibrio vulnificus infection with multiple endocrine neoplasia type I

A 35-year-old female with malabsorption syndrome who underwent a pancreatoduodenectomy for multiple endocrine adenomatosis 13 years prior was admitted to our hospital with diarrhea, general fatigue, high fever, and eruption in the lower legs. The patient had consumed raw shrimp a few days before onset and presented systemic inflammatory response syndrome at the time of hospitalization. Vibrio vulnificus was isolated from a blood culture performed before admission to the intensive care unit. We excised necrotizing tissue in the legs after improvement of her general condition. During the treatment process, glucose, catecholamine, and appropriate antibiotics were administered for hypoglycemia, hypotension, and high fever, respectively. The patient was discharged 107 days after contracting the disease. Of 18 septic patients with V. vulnificus infection admitted to our hospital, this was the first to develop septicemia in the absence of a previous liver dysfunction. In order to prevent this type of fatal infection, public education for immuno-compromised individuals as well as those with liver disease is essential. For early diagnosis and appropriate treatment, more effective strategies are required, such as the establishment of a network system where family physicians and emergency hospital staff could discuss information regarding high-risk patients.

A Collective Review of Vibrio vulnificus Infection in Japan

Vibrio vulnificus is found globally in marine coastal waters. Infection with this organism, via ingestion of raw shellfish or exposure to marine water, can cause necrotizing fasciitis and sepsis, which have high mortality and short latency. In Japan, many cases have been reported since 1980, mainly from hospitals in western prefectures. However, because of the sporadic nature of infection outbreaks, a thorough epidemiologic survey has not been done. We studied the epidemiological and clinical characteristics of Vibrio vulnificus infections reported in Japan from 1975 to 2005. We identified 185 cases using the medical article search engines Ichushi (Japan Medical Abstracts Society), CiNii (Citation Information by National Institute of Informatics), and PubMed over 30 years. The median age of patients was 59. The number of male patients was eight times the number of female patients; however, no significant difference in mortality was found between genders. In yearly distributions of patients, 20 cases were reported in 2001, a year in which we experienced more rainfall and a longer rainy season in Northern Kyushu. In monthly distribution, about 80% of cases were reported from July to September when sea water temperatures rise. About 40% of cases were reported in four prefectures around the Ariake Sea. The underlying disease indicated liver dysfunction in 90% of patients, but mortality was the same regardless of the infection pathway (oral ingestion or wound). Because of its rapid aggravation and high mortality rate, public education is important to prevent new cases. It is also highly recommended that patients with preexisting liver dysfunction avoid raw fish and limit exposure to marine water during the summer.

[Anesthetic management of combined lung volume reduction surgery and off-pump coronary artery bypass grafting]

A 54-year-old man with severe emphysema and stenosis of coronary artery was scheduled for combined surgery of lung volume reduction and an off-pump coronary artery bypass grafting. His FEV1.0 was 600 ml and %FEV1.0 was 18%. Coronary angiography showed 99% stenosis of the left anterior descending artery. Anesthesia was induced with propofol, fentanyl and vecuronium, and was maintained with sevoflurane and continuous epidural anesthesia. In order to avoid high airway pressure, a pressure-controlled ventilation (less than 15 cmH2O) was carried out. A laryngeal mask airway was replaced with an endotracheal tube after surgery to avoid bucking during extubation, and this was removed after recovery from anesthesia successfully. No complications were observed during anesthesia. Lung volume reduction surgery after coronary reconstruction by off-pump coronary artery bypass grafting may be beneficial for patients with emphysema and ischemic heart disease.

NOS II Inhibition Restores Attenuation of Endothelium-Dependent Hyperpolarization in Rat Mesenteric Artery Exposed to Lipopolysaccharide

The aim of this study was to assess the effects of lipopolysaccharide (LPS) exposure on the endothelium-dependent hyperpolarization in the rat mesenteric artery using isometric tension recordings and electrophysiological studies. Mesenteric arterial rings of male Sprague-Dawley rats were incubated with LPS for 6 hours. All experiments were performed in the presence of indomethacin to inhibit the formation of vasoactive prostanoids. Contraction to phenylephrine was significantly reduced in rings incubated with LPS, which was restored in the presence of N(omega)-nitro-L-arginine methyl ester (L-NAME). L-NAME resistant relaxation to acetylcholine was attenuated in LPS-treated rings. LPS exposure hyperpolarized resting membrane potentials of arterial smooth muscle cells, which was repolarized by incubation with either L-NAME or 1400W, a selective inhibitor of nitric oxide synthase II (NOS II). Endothelium-dependent hyperpolarization to acetylcholine was attenuated in arteries incubated with LPS, while incubation with LPS and 1400W restored EDHF-mediated hyperpolarization. LPS-induced membrane potential change was mimicked by incubation with either SIN-1 or diethylamine NONOate, a donor of nitric oxide. These data suggest that LPS exposure attenuates EDHF-mediated both relaxation and hyperpolarization in the rat mesenteric artery. The possible mechanisms underlying decreased EDHF-mediated responses might be due to, at least in some part, massive nitric oxide induced by NOS II.

[Perioperative administration of bicarbonated solution to a patient with mitochondrial encephalomyopathy]

A 16-year-old man with mitochondrial encephalomyopathy underwent biopsy and nephrectomy under general anesthesia. Mitochondrial encephalomyopathy is caused by mitochondrial dysfunction, and frequently accompanies elevation of lactic and pyruvic acid levels in the blood. It has been considered that problems of anesthesia for the patient with mitochondrial encephalomyopathy are the probability of hyperlactacidemia, the relevance to malignant hyperthermia, the possibility of myocardial disease and dysfunction of heart conduction system, respiratory depression due to muscle weakness, and so on. Therefore, to prevent hyperlactacidemia, we prepared the extracellular fluid solution including bicarbonic acid but no lactic and acetic acid, and infused the solution to the patient during anesthesia. By use of this solution, his lactic acid level was kept within the normal range during anesthesia and no metabolic acidosis occurred. His hemodynamics was stable and he showed normal response to vecuronium, recovering from anesthesia smoothly and postoperative course was uneventful.