Objective: To investigate which vital signs are relevant to cerebral oxygenation using near infrared spectroscopy (regional saturation of oxygen, rSO₂) as an index. Methods: Subjects were surgery patients who were managed using rSO₂ monitoring under anesthesia. Subjects included patients who had suffered lung tumors (LT) with resected lung lobes (LT group: n=50), those who suffered abdominal aortic aneurysms (AAA) and who underwent Y-type blood vessel grafts (AAA group: n=42), and those suffering from thoracic abdominal aortic aneurysms (TAAA) and who underwent thoracic and abdominal blood vessel prosthesis implantation (TAAA group: n=43). We investigated the perioperative values of respiratory and/or circulatory indices retrospectively, and investigated their correlations with rSO₂ values by multiple regression analysis. Results: The indices found to affect rSO₂ values were Hb, PaO₂ and PaCO₂ in the LT group; Hb and central venous oxygen saturation (ScvO₂) in the AAA group; body temperature (BT) and mixed venous oxygen saturation (SvO₂) in the TAAA group. Conclusions: We believe that Hb, PaO₂, PaCO₂ and BT are important indices for maintaining appropriate brain oxygenation.

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Cryoprecipitate is a blood product obtained by concentrating fresh frozen plasma (FFP). It is used as fibrinogen replacement therapy for patients with massive bleeding. In Japan, it is reported that cryoprecipitate is effective to treat massive hemorrhage during surgery, however, it is rarely used for trauma. In our hospital, a total of 6 trauma patients have received cryoprecipitate. The average fibrinogen level before infusion of cryoprecipitate was 99.2 mg/dl, and that of post infusion was 179 mg/dl. The average lactate level was 4.6 mmol/l before infusion and 3.5 mmol/l after infusion. One of the 6 patients died and the other 5 patients were discharged or transferred to another hospital for further rehabilitation. No adverse effects concerning cryoprecipitate infusion were seen in these patients. Cryoprecipitate infusion enables hemostasis by rapid replacement of fibrinogen for trauma patients with hypofibrinogenemia, and it may improve the survival prognosis.

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Nonconvulsive status epilepticus (NCSE) presents as a disorder of consciousness and has few other clinical findings. Electroencephalography (EEG) is crucial for its diagnosis. We analyzed 11 NCSE cases that presented with delayed emergence from anesthesia after cardiovascular surgery with cardiopulmonary bypass (CPB). EEG revealed epileptic spikes in all these cases, which were treated accordingly. NCSE was diagnosed in 11 of 433 cases of adult cardiovascular surgery with CPB, and 9 of 11 cases showed improvement in consciousness after treatment for epilepsy. Multivariate analysis revealed the following 4 risk factors for NCSE: arteriosclerosis obliterans, atrial fibrillation, CPB for more than 180 min, and use of tranexamic acid. NCSE should always be differentiated from the disorder of consciousness after cardiovascular surgery, and early EEG is necessary for its diagnosis. Furthermore, if EEG reveals epileptic spikes, patients should be treated accordingly. Moreover, intraoperative use of tranexamic acid is considered to be one of the risk factors for NCSE; therefore, it should be used selectively for cases at high risk of bleeding.

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We had difficulty in diagnosing two cases with urinary tract infection with urease-producing bacteria. <Case 1> A 71-year-old woman was admitted under emergency for disturbance of consciousness. Her consciousness level was Glasgow coma scale (GCS) E1V2M4 and her blood tests revealed an increased ammonia level of 299μg/dl. Brain CT and MRI, as well as cerebrospinal fluid examination demonstrated normal findings. The patient was subsequently diagnosed with a urinary tract infection with urease-producing bacteria, following which we intubated, and catheterized the bladder, and administered ampicillin/sulbactam. Six hours after admission, the blood level of ammonia decreased to 58μg/dl. The next day, the patient's consciousness level improved to GCS E4VTM6. Urine culture showed Corynebacterium urealyticum with urease-producing activity. <Case 2> A 67-year-old woman with disturbance of consciousness was admitted under emergency. Her consciousness level was GCS E1V2M4 and her blood tests revealed an increased ammonia level of 343μg/dl. Subsequently, we diagnosed the patients with urinary tract infection with urease-producing bacteria, and catheterized the bladder, following which cefozopran was administered. Six hours after admission, the blood level of ammonia decreased to 47μg/dl. Urine culture showed Klebsiella oxytoca with urease-producing activity. Both cases demonstrated, urinary retention with neurogenic bladder. Urinary tract infection by urease-producing bacteria must be considering in cases hyperammonemia with urinary retention.

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Parkinson's disease (PD) is a multiple system degenerative disease that involves autonomic failure as well as dysmobility. Recently, denervation supersensitivity of cardiac sympathetic nerves was proven to be present in patients with PD. However, it is not well understood how to use cardiovascular agents in such cases. A 78-year-old male (Hoehn-Yahr 5) presented at our hospital with severe lower abdominal pain and a high fever. He had experienced severe constipation for more than five days. Upon arrival, he was in a shock state, and his colon was markedly enlarged due to the presence of a large amount of stool and gas, as observed on an abdominal CT scan. Septic shock induced by intestinal pseudo-obstruction was suspected. Transanal anal drainage, fluid resuscitation based on early goal-directed therapy and antimicrobial treatment were performed immediately, although the patient’s MAP gradually decreased. Therefore, noradrenaline (NA) was administered, after which frequent premature ventricular contraction (PVC) appeared and the MAP failed to increase. After increasing the dose of NA, unsustained ventricular tachycardia (VT) occurred, and the MAP further reduced, in contrast to our aim. The cardiovascular agent was therefore changed from NA to vasopressin (VP), as a diagnosis of denervation supersensitivity was highly suspected. Thereafter, the arrhythmia significantly decreased, and the patient’s hemodynamic status improved. Cardiac sympathetic nerves begin to degenerate in the early phase of PD in association with increases in the number of cardiac adrenergic receptors and the induction of denervation supersensitivity. VP is a vasopressor that acts on V_1a receptors. The administration of VP should be considered in PD patients with denervation supersensitivity of the cardiac sympathetic nerves.

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