Three cases of difficulty in achieving definitive loss of consciousness with remimazolam

Abstract Background Remimazolam is a novel, ultra-short-acting benzodiazepine used for general anesthesia. Because remimazolam is an emerging drug, the tolerance to remimazolam in benzodiazepine-taking patients has been unclear. Also, the efficacy of remimazolam in different races is not fully elucidated so far. Case presentation Here we experienced three cases in which high dose of remimazolam was needed for attempting to achieve appropriate anesthetic depth. Two of the three cases were of preoperatively benzodiazepine-taking patients. The other was a case of a Chinese patient. In all three cases, conversion to general anesthesia with propofol was necessitated. Conclusions When signs of inadequate sedative effect of remimazolam are observed in patients of benzodiazepine users or of different races, conversion to another sedative agent such as propofol should be considered.

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Sinoorbital Mucormycosis Associated with Corticosteroid Therapy in COVID-19 Infection

Case Reports in Ophthalmological Medicine ◽

10.1155/2021/9745701 ◽

2021 ◽

Vol 2021 ◽

pp. 1-7

Author(s):

Zeinab Mehrabi ◽

Maryam Salimi ◽

Kianoush Niknam ◽

Farzaneh Mohammadi ◽

Hesan Jelodari Mamaghani ◽

...

Keyword(s):

Fungal Infection ◽

Medical History ◽

Corticosteroid Therapy ◽

Opportunistic Infections ◽

The Other ◽

High Dose ◽

Past Medical History ◽

Significant Past Medical History ◽

Predisposing Factor ◽

Case Presentation

Background. Mucormycosis is a rare and invasive fungal infection, affecting almost exclusively immunocompromised individuals. Immunosuppressive effects of corticosteroids which are widely prescribed in COVID-19 patients might be a predisposing factor for opportunistic infections even though the other factors should also be considered. Case Presentation. A middle-aged man without any significant past medical history was admitted to the hospital due to a severe COVID-19 infection. He received a high dose of corticosteroids as a part of the treatment. Five days after discharge, he presents with a headache and fever. Eventually, orbital mucormycosis was diagnosed for him and he was treated with antifungal medications. Conclusion. Opportunistic infections should be considered during the current pandemic of COVID-19, during which corticosteroids are widely prescribed.

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Allopurinol and Loss of Consciousness in a 78-old Year Man Suffering from Gout

Infectious Disorders - Drug Targets ◽

10.2174/1871526519666190128102039 ◽

2020 ◽

Vol 20 (2) ◽

pp. 253-256 ◽

Cited By ~ 1

Author(s):

Mahnaz Arian ◽

Mina AkbariRad ◽

Ahmad Bagheri Moghaddam ◽

Abdollah Firoozi ◽

Mohammad Jami

Keyword(s):

Uric Acid ◽

Xanthine Oxidase ◽

Kidney Stones ◽

Oxidase Inhibitor ◽

Loss Of Consciousness ◽

Drug Induced ◽

Xanthine Oxidase Inhibitor ◽

Case Presentation ◽

Maculopapular Rashes ◽

Reduced State

: Allopurinol is an FDA -Approved xanthine oxidase inhibitor, which is effective in the treatment of gout, hyperuricemia and uremic kidney stones in patients with an increased level of uric acid excretion. Xanthine oxidase acts by converting hypoxanthine and xanthine into uric acid, and therefore its inhibition results in decreased production of uric acid. The most common side effects of this medication are as follows: maculopapular rashes, hives, itching, headache, dizziness, abnormal hair loss, fever and hypersensitivity reaction. Case Presentation: This report represents a case of drug-induced meningitis of a senile man who ended up in the ICU due to the remarkably reduced state of consciousness.

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Muscle Tone Assessment under General Anesthesia for Sjögren-Larsson Syndrome and Spasticity

Pediatric Neurosurgery ◽

10.1159/000514329 ◽

2021 ◽

Vol 56 (2) ◽

pp. 163-165

Author(s):

George Georgoulis ◽

Argyrios Dinopoulos ◽

Emmanouil Gkliatis

Keyword(s):

General Anesthesia ◽

Muscle Tone ◽

Muscle Relaxants ◽

Spastic Diplegia ◽

Case Presentation ◽

Neurosurgical Procedure ◽

Dorsal Rhizotomy ◽

Severe Spasticity ◽

Larsson Syndrome ◽

Rule Out

Introduction: Study of muscle tone in individuals with severe spasticity (Modified Asworth Scale – MAS:3) under general anesthesia can confirm or rule out the eventual necessity of the impending spasticity relieving ablative neurosurgery by observing the hypertonia reduction and passive range of motion expansion. Therefore, what we measure under muscle relaxants is practically a fixed deformity. Case Presentation: The study was performed on a girl with Sjögren-Larsson syndrome, presenting with icthyosis and spastic diplegia. Proposed intervention was Dorsal Rhizotomy. Under general anesthesia, with and without muscle relaxants, hypertonia was significantly reduced (MAS:1), but the angle of motion did not increase much. Conclusion: We decided not to perform such a neurosurgical procedure. In ambiguous situations, the proposed study can help in decision-making for spasticity treatment.

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Transient maintenance of tracheal patency upon the insertion of a flexible bronchoscope in a patient with an anterior mediastinal mass: a case report

JA Clinical Reports ◽

10.1186/s40981-021-00442-y ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Takayuki Hasegawa ◽

Shinju Obara ◽

Rieko Oishi ◽

Satsuki Shirota ◽

Jun Honda ◽

...

Keyword(s):

General Anesthesia ◽

Mediastinal Mass ◽

Balloon Dilation ◽

Maximum Flow ◽

Anterior Mediastinal Mass ◽

Positive Pressure ◽

Anesthesia Induction ◽

Flexible Bronchoscope ◽

Case Presentation ◽

Tracheal Collapse

Abstract Background Patients with an anterior mediastinal mass are at risk of perioperative respiratory collapse. Case presentation A 74-year-old woman with a large anterior mediastinal mass that led to partial tracheal collapse (shortest diameter, 1.3 mm) was scheduled for tracheobronchial balloon dilation and stent placement under general anesthesia. Although veno-venous extracorporeal membrane oxygenation (V-V ECMO) had been established, maximum flow was limited to 1.6 L/min, and general anesthesia induction was followed by hypoxia probably due to inadequate ventilation. A flexible bronchoscope was inserted through the tracheal lumen that was being compressed by the anterior mass; this not only increased tracheal patency but also enabled positive pressure ventilation and resulted in recovery from hypoxia. Scheduled procedures were successfully performed without complications. Conclusion We describe a case wherein tracheal patency was transiently maintained by inserting a flexible bronchoscope in a patient with an anterior mediastinal mass.

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Excessive dynamic airway collapse during general anesthesia: a case report

JA Clinical Reports ◽

10.1186/s40981-020-00380-1 ◽

2020 ◽

Vol 6 (1) ◽

Cited By ~ 2

Author(s):

Shunichi Murakami ◽

Shunsuke Tsuruta ◽

Kazuyoshi Ishida ◽

Atsuo Yamashita ◽

Mishiya Matsumoto

Keyword(s):

General Anesthesia ◽

Airway Pressure ◽

Positive End Expiratory Pressure ◽

Computed Tomography Scan ◽

Case Presentation ◽

Airway Lumen ◽

Asthma Attack ◽

Airway Collapse ◽

History Of ◽

Tomography Scan

Abstract Background Excessive dynamic airway collapse (EDAC) is an uncommon cause of high airway pressure during mechanical ventilation. However, EDAC is not widely recognized by anesthesiologists, and therefore, it is often misdiagnosed as asthma. Case presentation A 70-year-old woman with a history of asthma received anesthesia with sevoflurane for a laparotomic cholecystectomy. Under general anesthesia, she developed wheezing, high inspiratory pressure, and a shark-fin waveform on capnography, which was interpreted as an asthma attack. However, treatment with a bronchodilator was ineffective. Bronchoscopy revealed the collapse of the trachea and main bronchi upon expiration. We reviewed the preoperative computed tomography scan and saw bulging of the posterior membrane into the airway lumen, leading to a diagnosis of EDAC. Conclusions Although both EDAC and bronchospasm present as similar symptoms, the treatments are different. Bronchoscopy proved useful for distinguishing between these two entities. Positive end-expiratory pressure should be applied and bronchodilators avoided in EDAC.

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ML-23 The outcome of malignant lymphoma of the central nervous system in a single institution

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa143.079 ◽

2020 ◽

Vol 2 (Supplement_3) ◽

pp. ii18-ii18

Author(s):

Kiyonori Kuwahara ◽

Shigeo Ohba ◽

Kazuyasu Matsumura ◽

Saeko Higashiguchi ◽

Daijiro Kojima ◽

...

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Adverse Events ◽

Malignant Lymphoma ◽

Survival Time ◽

Progression Free Survival ◽

Treatment Method ◽

The Other ◽

High Dose ◽

Other Hand

Abstract Background: Although high dose-methotrexate therapy has been performed for primary central nervous system malignant lymphoma (PCNSL), R-MPV (rituximab, methotrexate (MTX), procarbazine and vincristine) therapy is currently the first line therapy for (PCNSL) in our hospital. This study examines the results of R-MPV therapy comparing with past treatment. Method/Subjects: Thirty-seven patients treated at our hospital from 2009 to 2020 were included. Overall survival time, progression free survival time, and toxicities were evaluated. Results: The average age of patients was 65.7 years. Patients included 21 males and 16 females. Thirty-six patients were diagnosed DLBCL by resected brain tumor tissues, and one was diagnosed DLBCL by vitreous biopsy. As initial treatment, rituximab±HD-MTX therapy (R±MTX group) was performed in 20 cases, HD-MTX therapy plus radiation (R±MTX+RT group) was performed in 12 cases, and RMPV therapy was performed in 5 cases (R-MPV group). Median OS of all cases was 69 months and median PFS was 38 months. Median OS was 69 months in R±MTX group and could not be calculated in R±MTX+RT, and R-MPV groups. Median PFS was 16 months and 56 months in R±MTX group and R±MTX+RT, respectively, and could not be calculated in the R-MPV group. Although the R-MPV group had a short follow-up period, the results were considered to be comparable to those of the R±MTX+RT group. On the other hand, grade 3/4 adverse events occurred in 50%, 25%, and 100%, respectively. Conclusion: R-MPV therapy may delay the timing of radiation and reduce the amount of radiation. On the other hand, the frequency of adverse events is high, and more strict management of treatment is required.

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Severe acute myopathy following SARS-CoV-2 infection: a case report and review of recent literature

Skeletal Muscle ◽

10.1186/s13395-021-00266-5 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Badrul Islam ◽

Mohiuddin Ahmed ◽

Zhahirul Islam ◽

S. M. Begum

Keyword(s):

High Serum ◽

High Dose ◽

Limb Weakness ◽

Case Presentation ◽

Skeletal Myopathy ◽

Potential Marker ◽

Ventilatory Failure ◽

Muscle Magnetic Resonance Imaging ◽

Magnetic Resonance Imaging Mri ◽

Dose Corticosteroid

Abstract Background SARS-CoV2 virus could be potentially myopathic. Serum creatinine phosphokinase (CPK) is frequently found elevated in severe SARS-CoV2 infection, which indicates skeletal muscle damage precipitating limb weakness or even ventilatory failure. Case presentation We addressed such a patient in his forties presented with features of severe SARS-CoV2 pneumonia and high serum CPK. He developed severe sepsis and acute respiratory distress syndrome (ARDS) and received intravenous high dose corticosteroid and tocilizumab to counter SARS-CoV2 associated cytokine surge. After 10 days of mechanical ventilation (MV), weaning was unsuccessful albeit apparently clear lung fields, having additionally severe and symmetric limb muscle weakness. Ancillary investigations in addition with serum CPK, including electromyogram, muscle biopsy, and muscle magnetic resonance imaging (MRI) suggested acute myopathy possibly due to skeletal myositis. Conclusion We wish to stress that myopathogenic medication in SARS-CoV2 pneumonia should be used with caution. Additionally, serum CPK could be a potential marker to predict respiratory failure in SARS-CoV2 pneumonia as skeletal myopathy affecting chest muscles may contribute ventilatory failure on top of oxygenation failure due to SARS-CoV2 pneumonia.

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Formulating an anesthetic plan using a list of high-risk pregnant women on cloud-based business communication tools: a case report

JA Clinical Reports ◽

10.1186/s40981-021-00430-2 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Junnosuke Kimura ◽

Kento Kawamura ◽

Manami Minoura ◽

Ayako Hiramoto ◽

Yoshifumi Suga ◽

...

Keyword(s):

Case Report ◽

High Risk ◽

Cesarean Section ◽

General Anesthesia ◽

Pregnant Women ◽

Cesarean Delivery ◽

Business Communication ◽

Communication Tools ◽

Case Presentation ◽

Emergency Cesarean

Abstract Background We report a case in which a list of high-risk pregnant women on cloud-based business communication tools was useful in formulating an anesthetic plan for unscheduled cesarean section. Case presentation A 37-year-old woman, who had been prescribed icosapentate for hypertriglyceridemia, received an antenatal anesthetic evaluation for possible cesarean delivery, and it was agreed that the anesthetic method for emergency cesarean section was general anesthesia if the surgery would take place within 7 days after the discontinuation of the drug, and regional anesthesia if it would take place any time later. Then this agreement was uploaded on the cloud-based business communication tools, and updated until she delivered her baby via unscheduled cesarean section. Conclusions A cloud-based business communication tools was useful in formulating an anesthesia plan for a patient undergoing a cesarean delivery. However, more discussion would be needed to utilize it in security.

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Effects of the aqueous extract of Dicliptera verticillata on fertility and different stages of gestation in female rats

Zygote ◽

10.1017/s0967199420000921 ◽

2021 ◽

pp. 1-7

Author(s):

Stéphanie Ouabo Meguem ◽

Landry Lienou Lienou ◽

Marie Stéphanie Chekem Goka ◽

Richard Simo Tagne ◽

Didiane Mefokou Yemele ◽

...

Keyword(s):

Medicinal Plant ◽

Aqueous Extract ◽

Implantation Rate ◽

The Other ◽

Female Rats ◽

High Dose ◽

Immature Female ◽

Implantation Sites ◽

Parameters Analysis ◽

Hepatic Proteins

Summary Dicliptera verticillata is a medicinal plant traditionally used in western Cameroon to cure female infertility. This experiment was designed to assess the effects of the aqueous extract of Dicliptera verticillata (AEDv) on fertility and gestation in female rats. Oral increasing doses of AEDv were administered to immature female rats over 20 d. After this time, some animals were mated with fertile males and some fertility parameters were assayed; the other animals were euthanized for preliminary toxicity parameters analysis. The effects of AEDv on the different stages of gestation were assayed on selected animals previously controlled for estrous cycle regularity and mated. AEDv led to an increase in serum, uterine and ovarian proteins as well as in ovarian and uterine weights (P < 0.05) in immature female rats. Hepatic proteins significantly decreased (P < 0.01) in high dose-treated animals (50 and 100 mg/kg) compared with controls. The number of implantation sites and the fertility rate were significantly lower (P < 0.05), while the antifertility activity increased significantly (P < 0.05) in treated rats compared with controls. When administered from the 1st to the 5th day of pregnancy, AEDv led to a decrease of more than 60% in the implantation rate in high dose-treated rats (50, 100, and 400 mg/kg). From the 6th to the 9th day, the implantation, gestation rates and the number of fetuses decreased significantly in all treated groups. From the 11th to the 20th day, a 50% resorption and decrease in gestation rate were reported in 50 mg/kg dose-treated animals. AEDv possesses weak contraceptive and abortifacient effects during pregnancy.

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Multiple hepatic aneurysms and dry gangrene of fingertips in eosinophilic granulomatosis with polyangiitis: a case report

Allergy Asthma & Clinical Immunology ◽

10.1186/s13223-020-00484-4 ◽

2020 ◽

Vol 16 (1) ◽

Author(s):

Eunsil Koh ◽

Noeul Kang ◽

Jin-Young Lee ◽

Duk-Kyung Kim ◽

Young Soo Do ◽

...

Keyword(s):

Eosinophil Count ◽

Granulomatosis With Polyangiitis ◽

Stable State ◽

Clinical Situation ◽

High Dose ◽

Eosinophilic Granulomatosis With Polyangiitis ◽

Case Presentation ◽

The Right ◽

Small Aneurysms ◽

Eosinophilic Granulomatosis

Abstract Background Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis mainly affecting small-sized arteries. Involvement of medium-sized vessels is very rare in EGPA. Here we present the case of a patient with EGPA who showed multiple hepatic aneurysms and distal gangrene. Case presentation A known EGPA patient visited to the emergency room (ER) with abrupt squeezing abdominal pain. She had suffered from gangrene in the fingertips of both hands for 1 year because of arterial thrombosis associated with hypereosinophilia. However, her absolute eosinophil count in the ER was 1120 cells/µL. An abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe. A celiac angiogram demonstrated multiple sized aneurysms in both hepatic lobes and some aneurysms in S7 and S8 were huge, more than 1 cm in size. The shape of the small aneurysms resembled a string of beads, as in polyarteritis nodosa. Given the clinical situation, emergency embolization was performed. Before this patient visited to the ER, she had been treated with a high dose of systemic corticosteroid, azathioprine, and cyclophosphamide. After addition of mepolizumab, the eosinophil count remained stable state with a near zero percentage of total white blood cell count. Conclusions Aneurysm and gangrene resulting from the involvement of medium-sized vessels can occur in EGPA. Destruction of vessels might occur even if eosinophil count is below 1500 cells/µL. If involvement of medium-sized arteries is suspected, thorough investigation to identify the involved organs and prompt management are needed to prevent fatal complications.

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