Successful intraoperative management of laparoscopic hysterectomy in a patient with Eisenmenger syndrome: a case report

BACKGROUND

Patients with Eisenmenger syndrome (ES) requiring noncardiac surgery are at a significantly high risk of perioperative morbidity and mortality. However, perioperative management of patients with ES requiring laparoscopic surgery remains unclear.

CASE PRESENTATION

We describe the case of a patient with ES who underwent laparoscopic hysterectomy under general anesthesia with a peripheral nerve block. The objectives of the perioperative management included the following: (1) maintaining systemic vascular resistance and cardiac output through euvolemia, facilitated by the infusion of noradrenaline, and (2) preventing a reduction in oxygen-carrying capacity and factors that elevate pulmonary vascular resistance, such as pain, hypoxia, and decreased body temperature. Although laparoscopic procedures involved an increased risk in patients with ES, they are less invasive than open surgeries.

CONCLUSION

This report describes the successful anesthetic management of a patient with ES, ensuring a balance between systemic and pulmonary vascular resistance.

Reply to Su et al. Comment on "Matsumoto et al. Remimazolam's Effects on Postoperative Nausea and Vomiting Are Similar to Those of Propofol after Laparoscopic Gynecological Surgery: A Randomized Controlled Trial. J. Clin. Med. 2023, 12, 5402"

We thank the authors for their insightful and thoughtful commentary on our recent publication [...].

The Safety and Strategies for Reinitiating Electroconvulsive Therapy After ECT-Induced Takotsubo Cardiomyopathy: A Case Report and Systematic Review

OBJECTIVES

Takotsubo cardiomyopathy (TCM) is a life-threatening complication of electroconvulsive therapy (ECT). We report the case of a 66-year-old woman who was rechallenged with ECT after ECT-induced TCM. Moreover, we have made a systematic review to assess the safety of and strategies for reinitiating ECT after TCM.

METHODS

We searched for published reports on ECT-induced TCM since 1990 in MEDLINE (PubMed), Scopus, Cochrane Library, ICHUSHI, and CiNii Research.

RESULTS

A total of 24 ECT-induced TCM cases were identified. Patients who developed ECT-induced TCM were predominantly middle-aged and older women. There was no specific trend in anesthetic agents used. Seventeen (70.8%) cases developed TCM by the third session in the acute ECT course. Eight (33.3%) cases developed ECT-induced TCM despite the use of β-blockers. Ten (41.7%) cases developed cardiogenic shock or abnormal vital signs related to cardiogenic shock. All cases recovered from TCM. Eight (33.3%) cases tried to receive ECT retrial. The duration until ECT retrial was between 3 weeks and 9 months. The most common preventive measures during ECT retrial were related to β-blockers; however, the type, dose, and route of administration of β-blockers varied. In all cases, ECT could be reperformed without TCM recurrence.

CONCLUSIONS

Electroconvulsive therapy-induced TCM is more likely to cause cardiogenic shock than nonperioperative cases; nevertheless, it has good prognosis. Cautious reinitiation of ECT after TCM recovery is possible. Further studies are required to determine preventive measures for ECT-induced TCM.

Remimazolam's Effects on Postoperative Nausea and Vomiting Are Similar to Those of Propofol after Laparoscopic Gynecological Surgery: A Randomized Controlled Trial

(1) Background: Remimazolam is a novel benzodiazepine that prevents postoperative nausea and vomiting (PONV), is more effective than volatile anesthetics, and was recently approved for use in Japan. (2) Methods: This prospective, double-blind, randomized controlled trial study aimed to compare the efficacy of remimazolam and propofol as general anesthetics in terms of the incidence of PONV after laparoscopic gynecological surgery (UMIN000046237). High-risk female patients who underwent general anesthesia with either remimazolam or propofol for the maintenance of anesthesia were enrolled. The primary outcome was the incidence of PONV in the two groups (i.e., REM versus PROP) 2 h and 24 h after surgery. The incidence of vomiting without nausea, rescue antiemetic use, and the severity of nausea were also evaluated. (3) Results: No significant differences in PONV were identified between the REM and PROP groups at 2 h or 24 h. Furthermore, no differences were observed in any of the measured parameters, and no adverse events were reported. (4) Conclusions: The results of the present study suggest that remimazolam may be as effective as propofol in preventing PONV; however, further investigation is necessary to identify possible differences between these two agents.

Comparison of hemodynamics during induction of general anesthesia with remimazolam and target-controlled propofol in middle-aged and elderly patients: a single-center, randomized, controlled trial

BACKGROUND

Remimazolam confers a lower risk of hypotension than propofol. However, no studies have compared the efficacy of remimazolam and propofol administered using target-controlled infusion (TCI). This study aimed to investigate hemodynamic effects of remimazolam and target-controlled propofol in middle-aged and elderly patients during the induction of anesthesia.

METHODS

Forty adults aged 45-80 years with the American Society of Anesthesiologists Physical Status 1-2 were randomly assigned to remimazolam or propofol group (n = 20 each). Patients received either remimazolam (12 mg/kg/h) or propofol (3 μg/mL, TCI), along with remifentanil for inducing anesthesia. We recorded the blood pressure, heart rate (HR), and estimated continuous cardiac output (esCCO) using the pulse wave transit time. The primary outcome was the maximum change in mean arterial pressure (MAP) after induction. Secondary outcomes included changes in HR, cardiac output (CO), and stroke volume (SV).

RESULTS

MAP decreased after induction of anesthesia in both groups, without significant differences between the groups (- 41.1 [16.4] mmHg and - 42.8 [10.8] mmHg in remimazolam and propofol groups, respectively; mean difference: 1.7 [95% confidence interval: - 8.2 to 4.9]; p = 0.613). Furthermore, HR, CO, and SV decreased after induction in both groups, without significant differences between the groups. Remimazolam group had significantly shorter time until loss of consciousness than propofol group (1.7 [0.7] min and 3.5 [1.7] min, respectively; p < 0.001). However, MAP, HR, CO, and SV were not significantly different between the groups despite adjusting time until loss of consciousness as a covariate. Seven (35%) and 11 (55%) patients in the remimazolam and propofol groups, respectively, experienced hypotension (MAP < 65 mmHg over 2.5 min), without significant differences between the groups (p = 0.341).

CONCLUSIONS

Hemodynamics were not significantly different between remimazolam and target-controlled propofol groups during induction of anesthesia. Thus, not only the choice but also the dose and usage of anesthetics are important for hemodynamic stability while inducing anesthesia. Clinicians should monitor hypotension while inducing anesthesia with remimazolam as well as propofol.

TRIAL REGISTRATION

UMIN-CTR (UMIN000045612).

Effect of 10-minute prewarming plus intraoperative co-warming on core temperature maintenance during breast surgery compared to intraoperative co-warming alone: a randomized controlled trial

PURPOSE

We evaluated the effect of 10-min prewarming on core temperature maintenance during general anesthesia.

PATIENTS

We randomized 40 women scheduled for breast cancer surgery into 10-min Prewarming and Control groups. In the Prewarming group, a forced-air warming system was used to warm the patients at 43℃ for 10 min immediately before general anesthesia induction. In the Control group, the patients were kept warm using cotton thermal blankets for 10 min. We measured tympanic temperature every 15 min from anesthesia induction for 90 min.

FINDINGS

Since two patients deviated from the protocol, we used the data of 38 patients (Prewarming [n?=?18] and Control [n?=?20]). There was a significant between-group difference in changes in core temperature (P?=?0.03), including a significant difference in core temperature decrease during the first 60 min from anesthesia induction (Prewarming : -0.3 [0.3] ℃ vs. Control : -0.6 [0.2] ℃, P=0.02). In addition, the duration of normal core temperature maintenance was significantly longer in the Prewarming group (66 [34] min vs. 39 [32] min, P?=?0.01).

CONCLUSIONS

Ten-min prewarming decreases core temperature loss and contribute to maintaining normal core temperature during breast surgery. J. Med. Invest. 70 : 74-79, February, 2023.

Remimazolam decreased the incidence of early postoperative nausea and vomiting compared to desflurane after laparoscopic gynecological surgery

PURPOSE

Postoperative nausea and vomiting (PONV) is a common adverse event after surgery. Remimazolam is a novel sedative agent recently approved for general anesthesia in Japan. This study evaluated the efficacy of remimazolam in the incidence of PONV after laparoscopic gynecological surgery under general anesthesia.

METHODS

This prospective, randomized controlled trial included 64 women who underwent laparoscopic gynecological surgery. The patients were randomly assigned to undergo general anesthesia with either remimazolam (REM group) or desflurane (DES group, n = 30, each group). The primary outcome was the incidence of PONV in the two groups at 2 h and 24 h after the surgery. The incidence of vomiting, rescue antiemetic use, and severity of nausea were also evaluated.

RESULTS

In the REM group, the incidence of PONV (27% versus 60%, respectively; P = 0.02), rescue antiemetic use (0 versus 7, respectively; P = 0.01), and nausea score (P = 0.01) were significantly decreased during the first 2 h after surgery. No parameters were significantly different 24 h after surgery between the two groups.

CONCLUSION

Remimazolam can reduce the incidence of PONV after laparoscopic gynecological surgery compared to general anesthesia with desflurane during the early postoperative period.

Early Diagnosis of the Cardiopulmonary Collapse Type of Amniotic Fluid Embolism with Obstetrical Disseminated Intravascular Coagulation during Elective Cesarean Section : A Case Report

Two types of amniotic fluid embolism (AFE) have been described : cardiopulmonary collapse type and disseminated intravascular coagulation (DIC) type, with the latter proposed as uterine type. This report describes a healthy 28-year-old woman who developed AFE during a cesarean section. Because of a previous cesarean section, the patient underwent an elective cesarean section, under combined spinal-epidural anesthesia, at 38 weeks of pregnancy. She began coughing 5 minutes after delivery of the fetus, subsequently becoming unconscious and developing glossoptosis and bradycardia. Her blood pressure decreased to 76/43 mmHg, and AFE was suspected. Her uterus was atonic, and she experienced persistent noncoagulant bleeding, with a final blood loss of 6300 ml. Considerable blood transfusion was required. The patient survived, and she and her baby were discharged without any sequelae on the eighth postoperative day. This patient met the Japanese criteria for clinical AFE, with an obstetrical DIC score of 21 meeting the criteria for obstetrical DIC. Early diagnosis and treatment likely resulted in patient survival. J. Med. Invest. 67 : 207-210, February, 2020.

Assessment of postoperative nutritional status and physical function between open surgical aortic valve replacement and transcatheter aortic valve implantation in elderly patients

Background and aims : Severe aortic stenosis (AS) has been normally treated with surgical aortic valve replacement (AVR) whereas recently, transcatheter aortic valve implantation (TAVI) has been introduced as a minimally invasive operation for patients with high surgical risk and frailty. In this study, we have evaluated postoperative physical function and nutrition intake in the patients following AVR and TAVI. Methods : This prospective observational study involved 9 patients with surgical aortic valve replacement (AVR) and 7 patients with transcatheter aortic valve implantation (TAVI). Body composition was measured one day prior surgery, postoperative day (POD) 1, POD 3, POD 5 and POD 7. Hand grip strength, calf circumference and gait speed were measured one day before surgery and on the day of discharge. Results : Skeletal muscle was significantly decreased in AVR patients at postoperative day 3 and 7, while there was no change in TAVI patients. Patients with TAVI showed higher dietary intake after surgery compared to patients with AVR, and they maintained hand grip strength and calf circumference at discharge. Conclusions : In elderly patients with AS, TAVI can improve post-operative recovery maintaining nutritional status and physical function even. J. Med. Invest. 67 : 139-144, February, 2020.

Malignant hyperthermia in a 16-day-old infant with congenital diaphragmatic hernia: a case report

Malignant hyperthermia (MH) is a severe hypermetabolic disorder associated with dysregulation of calcium homeostasis and is triggered by inhalational anesthetics (isoflurane, sevoflurane, desflurane) and a depolarizing muscle relaxant (succinylcholine). We report the case of a 16-day-old infant undergoing laparoscopic surgery. The patient developed hyperthermia and hypercarbia with muscle rigidity. After the diagnosis of MH, dantrolene was administered with sufficient hydration. The patient was transferred to the pediatric intensive care unit for monitoring and treatment of acute renal injury due to myoglobinuria. Subsequently, two variants of the ryanodine receptor 1 (RYR1) gene were identified in the patient as the mutation point at c.1589G > A p.Arg530His and c.1841G > T p.Arg614Leu, which are known to be associated with MH. This was a rare case of MH in a 16-day-old infant that might be related to two RYR1 mutations inherited from the parents.

[Neurokinin-1 receptor antagonists for postoperative nausea and vomiting: a systematic review and meta-analysis]

BACKGROUND

Postoperative Nausea and Vomiting (PONV) is a common complication of general anesthesia. Several kinds of antiemetics, including 5-Hydroxytryptamine3 (5-HT3) receptor antagonists and Neurokinin-1 (NK-1) receptor antagonists, have been used to treat PONV.

OBJECTIVES

To compare the antiemetic effect of NK-1 receptor antagonists, including fosaprepitant.

DATA SOURCES

Online databases (PubMed, MEDLINE, Scopus, The Cochrane Library databases) were used.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized Controlled Trials (RCTs) performed in patients over 18 years with ASA-PS of I-III, aimed to assess the efficacy of antiemetics including NK-1 receptor antagonists and 5-HT3 receptor antagonists, and compared the incidence of PONV were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

All statistical assessments were conducted by a random effect approach and odds ratios and 95% Confidence Intervals were calculated.

RESULTS

Aprepitant 40mg and 80mg significantly reduced the incidence of vomiting 0-24hours postoperatively (Odds Ratio [OR = 0.40]; 95% Confidence Interval [95% CI 0.30-0.54]; p < 0.001, and OR = 0.32; 95% CI 0.19-0.56; p < 0.001). Fosaprepitant could also reduce the incidence of vomiting significantly both 0-24h and 0-48hours postoperatively (OR = 0.07; 95% CI 0.02-0.24; p < 0.001 and OR = 0.07; 95% CI 0.02-0.23; p < 0.001).

LIMITATIONS

Risk factors for PONV are not considered, RCTs using multiple antiemetics are included, RCTs for fosaprepitant is small, and some bias may be present.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Aprepitant and fosaprepitant can be effective prophylactic antiemetics for postoperative vomiting. However, more studies are required for higher-quality meta-analyses.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42019120188.

Postoperative nausea and vomiting following lower limb surgery :a comparison between single-injection intraarticular anesthesia and continuous epidural anesthesia

Study Objective : the incidence of postoperative nausea and vomiting (PONV) following single-injection intraarticular anesthesia was compared to that following continuous epidural anesthesia. Design : Prospective, double-blind, randomized study. Setting : University-affiliated teaching hospital. Patients : Forty-eight patients finally participated in this study, and each group contained twenty-four patients. Interventions : Patients scheduled to undergo lower limb surgery under general anesthesia were randomly allocated into two groups, to receive either single-injection intraarticular or continuous epidural anesthesia for postoperative analgesia. Measurements : The incidence and severity of PONV, complete response rates (i.e., no vomiting or rescue antiemetic use), and pain scores were recorded 2, 24, and 48 h postoperatively. Main results : No significant differences between groups were observed in the incidence and severity of PONV, rescue antiemetic use, or complete response rate at any of the time points, but only the use of rescue analgesics was significantly less in continuous epidural anesthesia group during the 2-24h postoperative period (P=0.04). Conclusion : While the use of single-injection intraarticular anesthesia following lower limb surgery did not prevent PONV more than continuous epidural anesthesia in this study, the intraarticular technique still provides greater simplicity, safety, and cost-effectiveness. J. Med. Invest. 66 : 303-307, August, 2019.

The effect of 1% glucose loading on metabolism in the elderly patients during remifentanil-induced anesthesia: a randomized controlled trial

Background

Previous studies showed that remifentanil-induced anesthesia can inhibit surgical stress response in non-diabetic adult patients and that low-dose glucose loading during anesthesia may attenuate fat catabolism. However, little is known about the influence of glucose loading on metabolism in elderly patients, whose condition may be influenced by decreased basal metabolism and increased insulin resistance. We hypothesized that, in elderly patients, intraoperative low glucose infusion may attenuate the catabolism of fat without causing harmful hyperglycemia during remifentanil-induced anesthesia.

Methods

Elderly, non-diabetic patients scheduled to undergo elective surgery were enrolled and randomized to receive no glucose (0G group) or low-dose glucose infusion (0.1 g/kg/hr. for 1 h followed by 0.05 g/kg/hr. for 1 h; LG group) during surgery. Glucose, adrenocorticotropic hormone (ACTH), 3-methylhistidine (3-MH), insulin, cortisol, free fatty acid (FFA), creatinine (Cr), and ketone body levels were measured pre-anesthesia, 1 h post-glucose infusion, at the end of surgery, and on the following morning.

Results

A total of 31 patients (aged 75–85) were included (0G, n = 16; LG, n = 15). ACTH levels during anesthesia decreased significantly in both groups. In the LG group, glucose levels increased significantly after glucose loading but hyperglycemia was not observed. During surgery, ketone bodies and FFA were significantly lower in the LG group than the 0G group. There were no significant differences in insulin, Cr, 3-MH, and 3-MH/Cr between the two groups.

Conclusion

Remifentanil-induced anesthesia inhibited surgical stress response in elderly patients. Intraoperative low-dose glucose infusion attenuated catabolism of fat without inducing hyperglycemia.

Trial registration

This study has been registered with the University hospital Medical Information Network Center (http://www.umin.ac.jp/english/). Trial registration number: UMIN000016189. The initial registration date: January 12th 2015.

Anesthetic management of a patient with methylmalonic acidemia: a case report

Background

Methylmalonic acidemia (MMA) is a metabolic disorder of organic acids and is characterized by the accumulation of methylmalonic acids.

Case presentation

The patient was a 19-year-old female diagnosed with severe MMA at 3 days of age, who was scheduled for renal replacement therapy. Preoperatively, there was no evidence of metabolic acidosis or electrolyte abnormalities. Glucose was administered preoperatively following a 6-h fast. Anesthesia was administered using thiamylal, remifentanil, rocuronium, and sevoflurane. After tracheal intubation, the patient underwent an ultrasound-guided bilateral rectus sheath block with ropivacaine. A drop in blood sugar level was treated with 5% glucose. Extubation was performed after intravenous administration of sugammadex.

Conclusions

We report the anesthetic management of a patient with MMA using a combination of general anesthesia and rectus sheath block.

Effectiveness of using non-invasive continuous arterial pressure monitoring with ClearSight in hemodynamic monitoring during living renal transplantation in a recipient:a case report

We investigated the effectiveness of the ClearSight system for hemodynamic management during kidney transplantation for a recipient. The recipient was to receive a kidney transplant from his mother under general anesthesia. We used continuous noninvasive finger-cuff-based monitoring of blood pressure, provided by the ClearSight system, and stroke volume variation to predict fluid responsiveness. We used of a balanced anesthetic technique and stringent monitoring standards to ensure a successful outcome for the patient. This case demonstrated that ClearSight has the potential to improve patient monitoring in hemodynamically stable patients who received kidney transplantation under general anesthesia. J. Med. Invest. 65:139-141, February, 2018.

The Efficacy of Programmed Intermittent Epidural Bolus for Postoperative Analgesia after Open Gynecological Surgery: A Randomized Double-Blinded Study

BACKGROUND

It is well known that the programmed intermittent epidural bolus (PIEB) technique effectively provides epidural anesthesia in labor. This randomized double-blind trial compared the postoperative analgesic efficacy of PIEB with that of continuous epidural infusion (CEI) in patients undergoing gynecological surgery under combined general-epidural anesthesia.

METHODS

Patients undergoing open gynecological surgery under combined general-epidural anesthesia were randomized at a 1 : 1 ratio to receive PIEB or CEI. In the PIEB group, the pump delivered 4 mL ropivacaine 0.2% plus fentanyl 2 μg/mL every hour. In the CEI group, the pump delivered the same solution at a rate of 4 mL/h. In both groups, additional 4 mL boluses of ropivacaine 0.2% plus fentanyl 2 μg/mL were provided, when necessary, by patient-controlled epidural analgesia after surgery. The primary outcome was the total ropivacaine dose 40 hours after surgery. The secondary outcomes were the number of PCEA boluses and postoperative pain (evaluated on an 11-point numerical rating scale) 3, 24, and 48 hours after surgery.

RESULTS

In total, 57 patients were randomized (n = 28 and 29 in the PIEB and CEI groups, resp.). The two groups differ significantly in terms of the total ropivacaine dose 40 hours after surgery (mean (standard deviation): 155.38 (4.55) versus 159.73 (7.87) mL, P = 0.016). Compared to the CEI group, the PIEB group had significantly lower numerical rating scale scores 3 hours (median [lower-upper quartiles]: 0 [0-0.5] versus 3 [0-5.5], P = 0.002), 24 hours (1 [0-2] versus 3 [1-4], P = 0.003), and 48 hours (1 [0-2] versus 2 [2-3.5], P = 0.002) after surgery.

CONCLUSION

PIEB was better than CEI in terms of providing postoperative analgesia after open gynecological surgery under combined general-epidural anesthesia.

Plasma substance P concentrations in patients undergoing general anesthesia: an objective marker associated with postoperative nausea and vomiting

Background

This study investigated plasma concentrations of substance P (SP) in patients undergoing general anesthesia (GA) and postoperative nausea and vomiting (PONV). This prospective, observational, cohort study included 23 patients who underwent scheduled surgery under general anesthesia. Blood was collected from the radial artery at predetermined time points (15-30 mins prior anesthesia, 15-30 mins after surgery/GA, and 24 h after surgery). PONV, SP concentrations, risk factors, and analgesics used were measured.

Findings

Nine of 23 patients experienced PONV. In patients without PONV, SP concentrations significantly decreased (P < 0.0001) at the end of surgery/GA, compared to baseline, and recovered at 24 h after surgery/GA (452.9 ± 146.2 vs. 666.9 ± 176.5 vs. 580.7 ± 168.6 pg/mL, respectively), whereas SP levels were unchanged during surgery/GA and increased at 24 hours after surgery (P = 0.020) in patients with PONV (726.1 ± 167.8 vs. 655.8 ± 168.0 vs. 779.7 ± 220.7 pg/mL, respectively).

Conclusions

These finding suggest that SP levels may be utilized as an objective marker for PONV.

General anesthesia of a Japanese infant with Barber-Say syndrome: a case report

Background

Barber-Say syndrome (BSS) is a very rare congenital disorder characterized by macrostomia, cutis laxa, and other features. We report our experience of performing general anesthesia on a Japanese child with BSS.

Case presentation

A bilateral repair of the corners of the mouth under general anesthesia was planned for an 18-month-old male with macrostomia; the child was 75 cm in height and weighed 9.9 kg. As insertion of the peripheral intravenous catheter was difficult, it was inserted before the surgery by a pediatrician. The patient wore a mask and was ventilated manually after loss of consciousness with intravenous anesthesia. A mask for adults provided a superior fit and was effective in preventing air leakage from the corners of the mouth. After rocuronium was administered, the larynx was spread with a Macintosh laryngoscope. There was no laryngeal anatomical abnormality, and tracheal intubation was readily possible. The operation was completed without incident. Stiffening of both arms occurred for several seconds one hour after the operation ended, but the patient did not develop other complications.

Conclusions

Mask ventilation and the insertion of an intravenous catheter may be difficult in the general anesthesia of patients with BSS, and anesthetic management requires caution.

Usefulness of central venous oxygen saturation monitoring during bidirectional Glenn shunt

A PediaSat™ oximetry catheter (PediaSat: Edwards Lifesciences Co., Ltd., Irvine, CA, U. S. A.), which facilitates continuous measurement of central venous oxygen saturation (ScvO2), may be useful for surgery for pediatric congenital heart disease. We used PediaSat during a bidirectional Glenn shunt. The patient was a 13-month-old boy. Under a diagnosis of left single ventricle (pulmonary atresia, right ventricular hypoplasia, atrial septal defect) and residual left aortic arch/left superior vena cava, a modified right Blalock-Taussig shunt was performed. Cyanosis deteriorated, so a bidirectional Glenn shunt was scheduled. After anesthesia induction, a 4.5 Fr double-lumen (8 cm) PediaSat was inserted through the right internal jugular vein for continuous ScvO2 monitoring. Furthermore, the probe of a near-infrared, mixed blood oxygen saturation-measuring monitor was attached to the forehead for continuous monitoring of the regional brain tissue mixed blood oxygen saturation (rSO2) (INVOS™ 5100C, Covidien; Boulder, CO, U. S. A.). Blockage of the right pulmonary artery and right superior vena cava decreased the oxygen saturation, ScvO2, and rSO2, but increased the central venous pressure. Although changes in ScvO2 were parallel to those in rSO2, the former showed more marked changes. A combination of ScvO2 and rSO2 for monitoring during Glenn shunt may be safer.

Recent less-invasive circulatory monitoring during renal transplantation

For anesthetic management during renal transplantation, it is necessary to maintain the blood flow and function of the transplanted kidney by performing massive fluid management and stabilizing blood pressure. We report anesthetic management for renal transplantation with a less-invasive circulatory monitoring system (Edwards Life Sciences Co., Ltd., Irvine, California, U.S.A.). In November 2010, renal transplantation was started in our hospital, and performed in 6 patients. In the first patient, fluid/circulatory management was conducted by connecting a standard arterial line and a standard central venous (CV) line. In the second patient, a FloTrac(TM) system and a standard CV line were used. In the third patient, a standard arterial line and a PreSep(TM) CV Oximetry Catheter were used. In the fourth and fifth patients, a FloTrac(TM) and a PreSep(TM) were used. In the latest patient, FloTrac(TM) and PreSep(TM) were connected to an EV1000(TM) Clinical Platform for fluid/circulatory management. The establishment of high-visibility monitors was useful for evaluating the condition and confirming the effects. As there are marked changes in hemodynamics, the CV pressure, which has been used as a parameter of fluid management, is not reliable in renal failure patients with a high incidence of cardiovascular complications. Advances in noninvasive circulatory monitoring with dynamic indices may improve the safety of anesthetic management during renal transplantation.

[Anesthesia for laser surgery of a tracheal tumor involving the carina: preservation of spontaneous breathing using remifentanil]

We describe anesthetic management of a patient with airway stenosis due to a tracheal tumor involving the carina. A 68-year-old man developed dyspnea and was scheduled for YAG laser surgery under general anesthesia. Awake fiberoptic intubation was selected for anesthesia induction, and percutaneous cardiopulmonary support (PCPS) was ready to be established prior to induction of anesthesia. Anesthesia was maintained with remifentanil (0.05 microg x kg(-1) x min(-1)) and propofol (2 mg x kg(-1) x hr(-1)), and spontaneous breathing was preserved throughout the surgical procedure. The operation was completed successfully without any adverse events, and PCPS was not used. In this patient, preservation of spontaneous breathing using remifentanil was found to be useful for airway management.

Neurokinin-1 receptor antagonism, aprepitant, effectively diminishes post-operative nausea and vomiting while increasing analgesic tolerance in laparoscopic gynecological procedures

PURPOSE

Post-operative nausea and vomiting (PONV) remains the most frequently reported patient complaint after anesthesia. Aprepitant is the first neurokinin-1(NK1) receptor antagonism available for use as an antiemetic. We investigated whether aprepitant can effectively decrease PONV in patients undergoing laparoscopic gynecological surgery.

METHODS

Sixty four patients receiving general anesthesia for laparoscopic gynecological surgery were randomly assigned to either receive a preoperative dose of 80 mg aprepitant or no drug. Efficacy was assessed in 2 and 24 hours after surgery. Primary and secondary endpoints were analyzed for the time intervals 0-2 hours (acute phase) and 2-24 hours (delayed phase). Vomiting, nausea, use of rescue anti-emetic, and visual analog scale (VAS) were assessed. Nausea was assessed on a 4-point scale, from 0 to 3.

RESULTS

Sixty patients participated in the study. At acute phase, PONV was present in both control and NK1 group and were 63% and 43% respectively. The severity of nausea was much less in the NK1 group. PONV prevalence at delayed phase was present in control but absent in NK1 group 27% vs. 0%, respectively. The amount of pain medication used by patients in the NK1 group was significantly less for diclofenac and pentazocine suggesting increase pain tolerance.

CONCLUSIONS

Neurokinin-1 receptor antagonism effectively lowered PONV increased pain tolerance, and expedited recovery in patients undergoing laparoscopic gynecological surgery.

[Anesthetic management of a patient with Becker muscular dystrophy]

We experienced anesthetic management of a patient with Becker muscular dystrophy. He had advanced dilated cardiomyopathy and high serum CK in the preoperative examinations. Anesthesia was planned to avoid triggering malignant hyperthermia or rhabdomyolysis and hemodynamic changes. Propofol, remifentanil and a minimum dose of rocuronium bromide were used for anesthetic induction and maintainance. Arterial pressure, cardiac output and stroke volume variation were monitored by Flotrac sensor. There were no adverse events observed during the anesthetic management. In conclusion, total intravenous anesthesia with the administration of rocuronium and circulatory monitoring by Flotrac sensor could be safe and efficient for anesthetic management of patients with Becker muscular dystrophy.

Differential effects of propofol and isoflurane on glucose utilization and insulin secretion

AIMS

Volatile anesthetics, such as isoflurane, reverse glucose-induced inhibition of pancreatic adenosine triphosphate-sensitive potassium (K(ATP)) channel activity, resulting in reduced insulin secretion and impaired glucose tolerance. No previous studies have investigated the effects of intravenous anesthetics, such as propofol, on pancreatic K(ATP) channels. We investigated the cellular mechanisms underlying the effects of isoflurane and propofol on pancreatic K(ATP) channels and insulin secretion.

MAIN METHODS

Intravenous glucose tolerance tests (IVGTT) were performed on male rabbits. Pancreatic islets were isolated from male rats and used for a perifusion study, measurement of intracellular ATP concentration ([ATP](i)), and patch clamp experiments.

KEY FINDINGS

Glucose stimulus significantly increased insulin secretion during propofol anesthesia, but not isoflurane anesthesia, in IVGTT study. In perifusion experiments, both islets exposed to propofol and control islets not exposed to anesthetic had a biphasic insulin secretory response to a high dose of glucose. However, isoflurane markedly inhibited glucose-induced insulin secretion. In a patch clamp study, the relationship between ATP concentration and channel activity could be fitted by the Hill equation with a half-maximal inhibition of 22.4, 15.8, and 218.8 μM in the absence of anesthetic, and with propofol, and isoflurane, respectively. [ATP](i) and single K(ATP) channel conductance did not differ in islets exposed to isoflurane or propofol.

SIGNIFICANCE

Our results indicate that isoflurane, but not propofol, decreases the ATP sensitivity of K(ATP) channels and impairs glucose-stimulated insulin release. These differential actions of isoflurane and propofol on ATP sensitivity may explain the differential effects of isoflurane and propofol on insulin release.

[Assessment of disposable crystal laryngoscope blade]

We evaluated Disposable Crystal Laryngoscope Blades in terms of preventing infection. Most anesthesiologists were satisfied with the view offered by the Disposable Crystal Laryngoscope Blade; however more force is necessary to lift the epiglottis during intubation. It may be more difficult to use by residents, inexperienced anesthesiologist, or emergency medical technicians, although the Disposable Crystal Laryngoscope blade is useful for preventing infection.

[Anesthetic management of a child with Angelman's syndrome]

Angelman syndrome is a hereditary disease described by Angelman. The clinical features of Angelman syndrome are characterized by mental retardation, puppet-like ataxia, easily excitable personality, seizures, paroxysmal laughter, strabismus and macroglossia. A 4-year-old girl with Angelman syndrome underwent strabismus repair under general anesthesia. Anesthesia was slowly induced with sevoflurane in oxygen and maintained with air, oxygen, propofol and remifentanil. Tracheal intubation was performed after administration of rocuronium. During and after anesthesia, no adverse events regarding circulatory and respiratory systems occurred. However, this case demonstrates that it is necessary to pay attention to airway troubles including the difficulty of tracheal intubation, management of body temperature and chronotropic action or respiratory depression by anesthetic agents.

A method for measurement of water temperature in micro-region using near infrared light

We have proposed a method for non-invasively measuring the temperature changes of water in a micro-region using near infrared (NIR) light. The goal of this study is to measure the temperature changes of biological cells or tissues. This method is on the basis of the phenomenon that the NIR absorption spectrum of water depends on temperature. First, in order to confirm whether a right irradiation for the temperature measurement itself affects the water temperature, we calculated the temperature rise caused by the optical absorption. Next, absorbance spectra in the wavelength range of 1300 - 2000 nm of water with a thickness of 100 and 500 m were measured by a micro-spectrometer. The measured spectra with temperature-dependence were calibrated using a regression analysis. The standard error of calibration was 0.6 C for 100 m-thickness.

Micro-thermocouple probe for measurement of cellular thermal responses

We have produced micro-thermocouple probes for the measurement of cellular thermal responses. Cells generate heat with their metabolisms and more heat with reactions to a certain physical or chemical stimulation. Therefore, the analysis of the cellular thermal responses would provide new physiological information. However, a real-time thermal measurement technique on a target of a single cell has not been established. In this study, glass micropipettes, which are widely used in bioengineering and medicine, are used for the base of the thermocouple probes. Using microfabrication techniques, the junction of two different metal films is formed at the micropipette tip with a diameter of 1 &#956;m. This probe can inject a chemical substance into a cell and to detect its subsequent temperature changes simultaneously.

Diamond-like carbon coating on micropipettes

Based on glass micropipettes which are widely used in bioengineering and medicine, various microsensor probes could be produced by recent microfabrication techniques. Conductive surfaces of these sensor probes mostly need electrical insulating films coated on them, but it has been difficult to coat a high-quality and strong insulating film on a microacute probe such as a micropipette, especially on its tip. Therefore, we have employed diamond-like carbon (DLC) as an insulating film and developed a DLC coating method based on plasma chemical vapor deposition method. In the deposition apparatus, the cathode is the micropipette itself and the anode is a mesh cylinder with a central focus on the micropipette. In order to prevent the growing films from transformation due to high temperature at the tip, the voltage between the pair of electrodes is impressed intermittently. Raman spectrum and electrical resistivity measured here indicate that the deposited film is DLC and it can be worked well as an insulating film. The DLC coating method could be useful in microprobe fabrications.

Estimation of radiative heat transfer using a geometric human model

In order to provide a detailed estimate of radiative heat transfer between a human body and its surrounding environment, we have developed a geometric model of a human form and an algorithm. The model closely resembles the actual shape of a human body and is composed of small quadrilateral surfaces. Dealing with an object or a space with an arbitrary shape, the developed algorithm can judge efficiently whether there is an obstruction between a pair of surfaces. As a result, the angle factors between a pair of surfaces that only occur during radiative heat transfer can be defined. The distribution of the radiative heat transfer rates shows the characteristics of body shape and variations in posture.

Development of a new algorithm for heat transfer equation in the human body and its applications

A computer program has been developed for the numerical analysis of thermal conditions within the human body. In this study, a cylindrical model, which consists of internal multi-layers, is adapted for the segment of the human body. For the present concentric cylindrical model we developed a new numerical solution method using a linear combination of the modified Bessel functions. By using the present computer program the internal tissue temperatures, heat fluxes and blood temperatures of the thigh, crus and foot segments are calculated. This paper describes a new algorithm solving heat transfer equation in the human body and the example of calculated results of the combination of thigh, crus and foot segments. The calculated results show the local characteristics of each segment in the human body.

Inflammatory cells and the epithelium. Mast cell/nerve interactions in the lung in vitro and in vivo

A hypothesis is presented that mast cells in and below the epithelium of the respiratory tract show functional association with nerves to form a homeostatic regulatory unit. During inflammation, mast cells may arise in situ as well as by infiltration because epithelium contains both mast cell precursors and produces factors that support their growth in vitro. Structural studies show that mast cells associate with nerves in the lung. Using a tissue culture model, we showed that sympathetic nerves formed lasting contacts with rat basophilic leukemia (RBL) cells. Electrophysiologic studies showed that nerve contact increases RBL membrane conductance, which can be mimicked by exogenous substance P (SP). Experiments with sensitized rat tracheal mucosa in Ussing chambers showed functional evidence of interaction of mast cells with SP-containing nerves: changes in short circuit current caused by antigen were blocked by the mast cell stabilizer doxantrazole and reduced by 50% by neonatal pretreatment with capsaicin. Experiments in vivo showed that lung clearance of the aerosol probe 99mTc-DTPA was increased by antigen challenge in sensitized rats. This was blocked by neonatal capsaicin treatment, again implicating SP-containing nerves. Therefore, we conclude that the functional association of mast cells with nerves is an important mechanism in regulating the local epithelial environment.