Pathophysiology during ECC

Extracorporeal circulation, unlike pulsatile flow based on the beating heart, is the non-pulsatile flow through a blood pump, and the systemic circulation falls into non-physiological conditions. The living body shows various reactions to extracorporeal circulation. The pathophysiology of extracorporeal circulation includes changes in hemodynamics, coagulation, fibrinolysis, acid-base equilibrium, electrolytes, incretion, metabolism, and immune system. With advances in extracorporeal circulation technology, operability has been dramatically improved and safety has rapidly advanced as well. However, there are specific complications with extracorporeal circulation. We need to have a good knowledge of the pathophysiology and complications during extracorporeal circulation, as well as each component of the extracorporeal circulation system

シュウジュツキ ノ ケッカン キノウ ホゴ センリャク

Potassium channels play an essential role in the membrane potential of arterial smooth muscle, and also in regulating contractile tone. Especially, in vascular smooth muscle, the opening of adenosine triphosphate（ATP）-sensitive potassium（KATP）channels leads to membrane hyperpolarization, resulting in muscle relaxation and vasodilation. This activation also plays a role in tissues during pathophysiologic events such as ischemia, hypoxia, and vasodilatory shock. In this review, we will describe the physiological and pathophysiological roles of vascular smooth muscle KATP channels in relation to the effects of anesthetics and perioperative managements. Although accumulated evidence suggests that many anesthetics and perioperative managements（especially, diabetes and hyperglycemia）modify the above function of K+ channels as a metabolic sensor. Use of effective volatile anesthetics and the strict glycemic control may contribute to protect perioperative vascular function

A case where rocuronium was unable to achieve neuromuscular block immediately after sugammadex administration

We present a case where immediatemuscle relaxation was needed following sugammadex administration. A 72 year-old female underwent surgery for a cerebral artery aneurysm. Upon conclusion of the operation sugammadex (9.3 mg/kg) was administered and the patient was noted to have left hemiplegia. Rocuronium (1.2 mg/kg 2 doses) was given in order to gain neuromuscular block approximately 25 minutes after sugammadex had been injected. Although TOF monitoring was not utilized in this case and assessing residual muscular block was difficult, spontaneous respirations continued and breathing had to be controlled with sevoflurane and remifentanil. Sugammadex is a potent reversal agent for rocuronium-induced neuromuscular block, however, certain situations require immediate neuromuscular blockade following sugammadex. In this case, rocuronium was unable to induce neuromuscular blockade immediately after sugammadex and that higher concentrations were necessary in addition to intravenous analgesics and inhaled anesthetics

Clinical clerkship students’ preferences and satisfaction regarding online lectures during the COVID-19 pandemic

Background: The COVID-19 pandemic has caused an unprecedented disruption in medical education. Students and lecturers had to adapt to online education. The current study aimed to investigate the level of satisfaction and future preference for online lectures among clinical clerkship students and elucidated the factors that affect these outcomes. Methods: We selected a sample of 114 medical students undergoing clinical clerkship during the COVID-19 pandemic. We conducted onsite lectures before the pandemic and online lectures after the outbreak. A survey was conducted, and the sample included students and 17 lecturers. The average scores of total satisfaction and future preference related to online lectures were computed. Results: Students’ scores on total satisfaction with online lectures and their future preference were higher than those for onsite lectures. Scores on the ease of debating dimension were low and those on accessibility of lectures in online lectures were higher than those in onsite lectures. There was no difference between the two groups in the scores on the comprehensibility and ease of asking questions dimensions. Results of the multiple regression analysis revealed that accessibility determined total satisfaction, and future preference was determined by comprehensibility as well as accessibility. Contrary to students’ future preferences, lecturers favored onsite lectures to online ones. Conclusion: Online lectures are an acceptable mode of teaching during the COVID-19 pandemic for students undergoing clinical clerkship. Online lectures are expected to become more pervasive to avoid the spread of COVID-19

Adult onset IgAV

Immunoglobulin A vasculitis (IgAV), formerly known as Henoch-Schönlein purpura, primarily occurs during childhood between the ages of 3 and 15 years and is the most common form of systemic vasculitis in children ; its occurrence in adults has been rarely reported. Such low incidence could be attributable to either under-diagnosis or misdiagnosis. Thus, not only pediatricians but also physicians should be able to diagnose IgAV accurately to manage the patients appropriately and avoid its associated complications. In addition, treatment of adult onset IgAV with renal involvement has not been fully established yet. We describe here a case of adult onset IgAV complicated by proteinuria and pharyngitis, which was cured by no specific treatment

Continuous blood glucose monitoring during pediatric cardiopulmonary bypass

The purpose of this study was to assess the accuracy and efficacy of a continuous blood glucose monitoring system (artificial endocrine pancreas; STG-22, Nikkiso, Co., Ltd., Tokyo, Japan) during pediatric cardiopulmonary bypass. Sixteen pediatric patients scheduled to undergo cardiovascular surgery with cardiopulmonary bypass (6 for atrial septal defects, 8 for ventricular septal defects and 2 for others, age: 7 months to 13 years, body weight 6.4-55.4 kg) were enrolled. The glucose sensor line of the artificial endocrine pancreas was connected to the venous side of the cardiopulmonary bypass circuit and used for continuous blood glucose monitoring. We obtained 66 samples for blood gas assessment from the cardiopulmonary bypass circuit, and i-STAT (Abbott, East Windsor, NJ, USA) was used for conventional blood glucose assessment. Data were analyzed with simple linear regression analysis using the Bland and Altman approach. After cardiopulmonary bypass was started and the aortic artery clamped, the blood glucose level rose markedly to around 300 mg/dl. Blood sampling via the venous side of the cardiopulmonary bypass circuit showed that continuous blood glucose monitoring was stable and reliable even during pediatric cardiovascular surgery with cardiopulmonary bypass. A close correlation (R = 0.97) was observed between continuous glucose measurement and conventional intermittent glucose measurements. The results of this continuous blood glucose monitoring system for cardiopulmonary bypass during pediatric cardiovascular surgery were highly reliable

Successful treatment of mixed (mainly cancer) pain by tramadol preparations

The patient, a 70-year-old Japanese woman diagnosed with parotid gland cancer, underwent wide excision and reconstruction (facial nerve ablation, nerve transposition). At 1 month after the surgery, she was brought to our hospital’s pain medicine department because her postoperative pain and cancer-related pain were poorly controlled. She had already been prescribed a tramadol (37.5 mg)/acetaminophen (325 mg) combination tablet (5 tablets/day). However, in addition to the continuous pain in her face and lower limbs, she was troubled by a trigeminal neuralgia-like prominence ache. Because this pain could not be controlled by an increase to eight combination tablets per day, we switched her medication to a tramadol capsule. At 11 months post-surgery, we then switched her medication to an orally disintegrating tramadol tablet to improve medication adherence of the drug. From 14 months post-surgery, the patient also used a sustained-release tramadol preparation, and she was then able to sleep well. Her current regimen is an orally disintegrating sustainedrelease tablet combination (total 300 mg tramadol) per day, and she achieved sufficient pain relief. Because tramadol is not classified as a medical narcotic drug, it widely available and was shown here to be extremely useful for the treatment of our patient’s mixed (mainly cancer) pain

Impact of newly developed, next-generation artificial endocrine pancreas

Background : Recent studies have shown that strict perioperative blood glucose management may reduce mortality and morbidity in critically ill adult patients. The purpose of this study was to assess the accuracy and efficacy of the intraoperative application of a newly developed, next-generation artificial endocrine pancreas (STG-55, Nikkiso Co., Ltd., Tokyo, Japan). Methods : Twenty patients scheduled to undergo surgery were enrolled in this study. The STG-55 is designed to be more user-friendly than its conventional counterpart (STG-22) while maintaining the latter’s fundamental functions, such as a closed-loop system using algorithms for insulin and glucose infusion. After anesthetic induction, a 20G intravenous catheter was inserted into a peripheral forearm vein and connected to a continuous blood glucose monitor. The resultant 105 scores for paired blood glucose values were compared by Bland-Altman analysis. Results : Stable blood glucose values were maintained automatically, and there were no complications related to use of the STG-55. A close correlation (r=0.96) was observed between continuous glucose measurements using the STG-55 and conventional intermittent glucose measurements. The difficulty of manipulation using this system was decreased by improved preparation procedures. Conclusion : The glycemic control system using the STG-55 could provide an alternative way to achieve effective and safe perioperative glycemic control