Background: Although the antiemetic effect of olanzapine on chemotherapy-induced nausea and vomiting has been characterized, the prophylactic role of olanzapine on postoperative nausea and vomiting (PONV) has not been fully elucidated. This clinical trial aims to examine the effectiveness of olanzapine for preventing PONV. Methods: Patients undergoing laparoscopic gynecological surgery at 5 university hospitals in Japan will be randomly assigned to receive either 5 mg of oral olanzapine or placebo 2 hours before the induction of anesthesia. All patients will receive intravenous dexamethasone at the induction of anesthesia. The primary outcome will be the incidence of postoperative nausea and vomiting within 24 hours after surgery. Secondary endpoints will include longitudinal changes in the incidence of postoperative nausea and vomiting and overall patient satisfaction. Discussion: This trial will provide a high quality evidence whether olanzapine prevents PONV in gynecological laparoscopy patients at a high risk for PONV. Ethics and dissemination: The trial was approved by the institutional review board of the each participating study site. Study findings will be disseminated through peer-reviewed publications and in conference presentations. Trial registration: UMIN Clinical Trials Registry (UMIN-CTR) ID: 000022634, Registered on October 1, 2016 https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000026031

Background: Primary peritonitis due to Streptococcus pyogenes (S. pyogenes) is uncommon in patients without comorbid conditions such as immunosuppression, nephritic disease, or liver cirrhosis. Furthermore, it does not cause another infection at the same time in a healthy person. However, several S. pyogenes mutants have been reported, and some of them exhibit strong virulence. Mutation of the control of virulence (cov) S gene of Streptococcus enhances bacterium survival by repressing negative regulators of virulence, which causes bacterial invasion of aseptic tissues, such as the parenteral space. We report a case of primary peritonitis and subsequent necrotizing fasciitis by the same S. pyogenes species with mutated covS in a previously healthy woman. Case presentation: We present the case of a 55-year-old woman admitted to the hospital due to abdominal pain and nausea. She was treated for peritonitis. A few days later, she became hypotensive and tachycardic and was transferred to the intensive care unit (ICU) for the treatment of septic shock with primary peritonitis. On the second day of her ICU stay, both of her forearms developed swelling and redness around the peripheral injection site. The patient had developed necrotizing fasciitis. Since her skin symptoms spread rapidly, urgent debridement was performed. Her condition improved with antibiotic treatment and multiple episodes of debridement. S. pyogenes was detected in cultures of the patient's blood, ascites, and skin. The identified strain was emm89 genotype and had a genetic mutation of covS. Conclusions: S. pyogenes with covS mutation may spread from a portal, such as the upper respiratory tract or digestive system, to all organs immediately, causing septic shock. Infection with S. pyogenes with mutated genes should be considered in the differential diagnosis of gastrointestinal symptoms, even in a previously healthy patient.

Objective：To describe two cases of postoperative septic shock after endoscopic combined intrarenal surgery (ECIRS) that were managed well by early recognition and early intervention by anesthesiologists. Case presentation： ［Case 1］ECIRS was performed to treat a stone in the left kidney of a 56-year-old woman. She fell into a state of shock immediately after removal of her tracheal tube in the operating room. She was diagnosed with sepsis based on quick SOFA score and other findings and was treated in the intensive care unit for three days.［Case 2］ECIRS was performed to treat stones in the right kidney of a 39-year-old woman who suffered from recurrent urinary tract infections. After the procedure, her condition deteriorated during her stay in the postanesthesia care unit. She was treated in the intensive care unit for three days for septic shock. Conclusion：Although its incidence is rare, septic shock is one of the most important complications associated with patients who have undergone ECIRS.