Language：Japanese   Publisher：日本手術医学会  

周麻酔期看護師は2010年に聖路加国際大学大学院で養成が開始され、人数、就労施設ともに増加傾向にある。2年間の修士課程を修了後、院内認定資格として、麻酔科医の指示・監督の下、手術室内外で行われる麻酔科診療の補助業務を行っている。横浜市立大学では2014年に周麻酔期看護師が業務を開始した。当時、先行施設である聖路加国際病院以外の施設に周麻酔期看護師が就労することは初めてであり、全国的に見ても先駆的な試みであった。周麻酔期看護師が安全に業務を遂行することができる環境やシステム作りを模索しながら行い、神奈川県内の周麻酔期看護師は現在、4施設(横浜市立大学附属病院、横浜市立大学附属市民総合医療センター、横浜市立市民病院、聖マリアンナ医科大学横浜市西部病院)に計8名となった。業務内容は施設によって異なるが、手術麻酔、麻酔科術前外来、手術室外で行われる麻酔のアシスタント、院内看護師や周麻酔期看護大学院生に対する教育などに関与している。横浜市立大学で行った、周麻酔期看護師の関与と麻酔関連合併症に関する研究では、麻酔科医の監督下で周麻酔期看護師が麻酔管理に関与することは合併症の発生頻度に差を認めず、安全性も確保されていると考える。周麻酔期看護師が導入されたことで、麻酔科の業務が拡充するなどの効果を認めており、周麻酔期看護師は麻酔科医と協調し、周術期医療のさらなる安全性の向上に貢献している。(著者抄録)

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Language：Japanese   Publisher：真興交易(株)医書出版部  

2015年4月〜10月に周麻酔期看護師または麻酔科後期研修医による経口気管挿管を受けた18歳以上の手術患者を対象として、気管挿管の合併症の発生頻度および挿管施行回数を比較した。対象期間内に2名の周麻酔期看護師と9名の麻酔科後期研修医が在籍し、周麻酔期看護師はすべてビデオ喉頭鏡を使用し、麻酔科後期研修医は使用する喉頭鏡の制限を設けなかった。対象患者は周麻酔期看護師による挿管が130例(周麻群)、麻酔科後期研修医による挿管が1011例(研修医群)であり、挿管の合併症は周麻群2例(1.5%)、研修医群34例(3.4%)で両群間に有意差は認めなかった。挿管施行回数は周麻群中央値1(最小値-最大値、1-2)のほうが、研修医群中央値1(最小値-最大値、1-5)に比べ有意に少なかった。

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Language：English   Publishing type：Research paper (scientific journal)  

The aim of this special article is to introduce Perianesthesia Nurses (PANs) who play an essential role in assisting anesthesiologists to ensure the safety of patients undergoing anesthesia and to improve the quality of anesthetic care. In Japan, there is no national license for nurse anesthesia providers. Therefore, most of the tasks related to anesthesia are performed by the anesthesiologists. Due to the size and complexity of the aging population, higher quality perioperative care is needed. In search of a solution, PANs were introduced to improve anesthetic care in Japan, enabling anesthesiologists to delegate some of their tasks to PANs who work within the scope of registered nurse's policies. They are a new type of anesthesia care provider in Japan, and different from Certified Registered Nurse Anesthetists in the United States. Currently, six schools provide 2-year master's degree perianesthesia nursing programs, and graduates are now providing anesthetic care both inside and outside of the operating room under the direct supervision of anesthesiologists. PANs not only assist anesthesiologists and help to reduce anesthesiologists' workload, but also contribute to the expansion of anesthesia services. They ensure patient safety and improve the quality of patient care before, during, and after the patient undergoing anesthesia.

DOI： 10.1007/s00540-020-02826-3

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Language：Japanese   Publisher：日本手術医学会  

周麻酔期看護師とは、麻酔にかかわる術前から術後までの医療の流れの中で、患者にとって最善の麻酔が施されるように看護師として麻酔業務を補助する役割を果たす者として、2010年に聖路加国際大学大学院修士課程で養成が開始された。2016年度には横浜市立大学大学院修士課程に同様の教育課程が開講した。筆者は、横浜市立大学大学院周麻酔期看護学分野の1期生として2018年に修士課程を修了し、同年から周麻酔期看護師として活動している。現在までに、本邦では6大学で養成が行われ、各施設で周麻酔期看護師が活動しており、その活動の場はより一層の広がりを見せている。一方、公的には未確立な制度であること、標準化された教育プログラムがないため各養成施設が手探りで実施しているという課題もある。周麻酔期看護学の発展やチーム医療、麻酔医療の安全と質の向上に貢献するためにも、教育の情報を発信・共有していくことは重要である。本稿では筆者が修士課程中に経験した周麻酔期看護学実習について報告する。筆者は、約1年半の実習の中で145症例を経験した。本学では、麻酔科医とマンツーマンで担当麻酔症例の麻酔計画について、綿密なディスカッションを繰り返すことを基本とした実習が行われる。質の担保された周麻酔期看護師の育成にあたり、教育プログラムの確立や実習後の評価方法の確立が今後必要になると考えられた。(著者抄録)

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Language：Japanese   Publisher：日本手術医学会  

横浜市立大学では、2014年に周麻酔期看護師が業務を開始し5年が経過した。現在、横浜市立大学附属病院には3名の周麻酔期看護師が在籍し、麻酔科の診療の補助業務を行っている。現在の主な業務内容は手術麻酔であり、術前・術後診察を含め、手術麻酔に関わる一連のケアの提供を麻酔科医の指示・監督下で行っている。当院では2018年度の1年間に麻酔科管理症例が5313件あり、周麻酔期看護師はそのうちの781件(14.6%)に関与した。当院では周麻酔期看護師が導入されたことで、手術室以外の重要な麻酔関連業務に麻酔科医を配置することが可能となった。麻酔科医の業務が拡がり、無痛分娩とRapid Response Teamが開始され、患者サービスの向上につながった。(著者抄録)

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Language：Japanese   Publisher：(一社)医療の質・安全学会  

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Publishing type：Research paper (scientific journal)   Publisher：Springer Science and Business Media LLC  

DOI： 10.1186/s13054-024-05222-5

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Other Link： https://link.springer.com/article/10.1186/s13054-024-05222-5/fulltext.html

Language：English   Publishing type：Research paper (scientific journal)  

Cesarean deliveries are often performed under spinal anesthesia because of the reduced risk of complications compared with that of general anesthesia. However, hypotension frequently occurs and adversely affects both the mother and fetus. Indices, such as the perfusion index (PI) and pleth variability index (PVI), which are derived from pulse oximetry have been used in numerous studies to predict hypotension after spinal anesthesia. However, their predictive abilities remain controversial. This study aimed to investigate the ability of PI and PVI, measured before the initiation of spinal anesthesia, to predict hypotension after spinal anesthesia in patients undergoing cesarean deliveries. To this end, we conducted a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, European Union Clinical Trials Register, World Health Organization International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry databases from inception until June 15, 2023. We included retrospective and prospective observational studies and randomized controlled trials that assessed the ability of PI and PVI, measured before the initiation of spinal anesthesia, to predict hypotension after spinal anesthesia during cesarean delivery. We did not restrict our search to specific languages. Of the 19 studies, involving 1437 patients, 17 assessed the PI in 1,311 patients, and 5 assessed the PVI in 344 patients. The summary sensitivity and specificity of the PI were 0.75 (95% confidence interval [CI]: 0.69-0.80) and 0.64 (95%CI: 0.48-0.77), respectively, while those of the PVI were 0.63 (95%CI: 0.47-0.76) and 0.76 (95%CI: 0.64-0.84), respectively. The area under the summary receiver operating characteristic curve was approximately 0.75 for both indexes. Baseline PI and PVI have a moderate predictive ability for hypotension after spinal anesthesia in patients undergoing cesarean delivery.

DOI： 10.1371/journal.pone.0316715

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PURPOSE: The application of immune checkpoint inhibitors (ICIs) can cause multi-organ adverse events, namely immune-related adverse events (irAEs) in patients with cancer. This study aimed to characterize the epidemiological information on irAEs in patients with cancer referred to the palliative care team (PCT). METHODS: The medical records of cancer patients with a history of ICI therapy referred to the PCT at a tertiary care center between January 2017 and July 2022 were retrospectively reviewed in this single-center, observational study. RESULTS: The median age of the 140 patients was 68 years, and lung (39.3%) being the most common primary site. We observed irAEs in 46 patients (32.9%), and hypothyroidism was the most common irAE. For irAEs graded ≥ 3 in 21 patients, pneumonitis was the most common adverse event. As for strategies for management with irAEs, seventeen patients were treated with systemic steroids. irAEs ( +) had a significantly lower Performance Status at the start of ICI, a higher total number of ICI doses, and longer duration from start of ICI to date of death than irAEs (-). CONCLUSIONS: Among 140 cancer patients with a history of ICIs therapy consulted to the PCT, the prevalence of irAEs was 32.9%, and 21 patients (15.0%) developed irAEs with grade ≥ 3. As the use of ICI is expected to increase in the future, it is important for palliative care physicians to increase their awareness of the management of irAEs and collaborate with oncologists from an early stage.

DOI： 10.1007/s00520-024-09012-1

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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BACKGROUND: The occurrence of hypotension after induction of general anaesthesia is common in geriatric patients, and should be prevented to minimise perioperative complications. Compared with propofol, remimazolam potentially has a lower incidence of hypotension. This study aimed to compare the incidence of hypotension after general anaesthesia induction with remimazolam or propofol in geriatric patients. METHODS: This single-centre, double-blind, randomised trial enrolled 90 patients aged ≥80 yr who received general anaesthesia for scheduled surgery. Patients were randomised to receive remimazolam (12 mg kg-1 h-1) or propofol (0.025 mg kg-1 s-1) for anaesthesia induction, with remifentanil and sevoflurane. The presence or absence of hypertension on the ward served as the stratification factor. The incidence of hypotension after the induction of general anaesthesia, defined as a noninvasive mean arterial pressure of <65 mm Hg measured every minute from initiation of drug administration to 3 min after tracheal intubation, was the primary outcome. Subgroup analysis was performed for the primary outcome using preoperative ward hypertension, clinical frailty scale, Charlson Comorbidity Index, and age. RESULTS: Three subjects were excluded before drug administration, and 87 subjects were included in the analysis. The incidence of hypotension was 72.1% (31/43) and 72.7% (32/44) with remimazolam or propofol, respectively. No statistically significant differences (adjusted odds ratio, 0.96; 95% confidence interval, 0.37-2.46; P=0.93) were observed between groups. Subgroup analysis revealed no significant differences between groups. CONCLUSIONS: Compared with propofol, remimazolam did not reduce the incidence of hypotension after general anaesthesia induction in patients aged ≥80 yr. CLINICAL TRIAL REGISTRATION: UMIN000042587.

DOI： 10.1016/j.bja.2024.04.013

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Language：Japanese   Publisher：克誠堂出版(株)  

＜文献概要＞妊娠中の不安は,周産期の母体のメンタルヘルスに重大な影響を与えうる。無痛分娩の麻酔に関する説明動画を視聴することで妊婦の不安が軽減するか観察研究で検討した。無痛分娩を行う予定の18歳以上の妊婦を対象とし,オリジナルで作成した無痛分娩の麻酔に関する説明動画を分娩誘発前日に視聴した。動画視聴の前後でhospital anxiety and depression scale(HADS)への回答を依頼し,その不安項目(HADS-A)の変化を主要評価項目とした。15名の妊婦を対象に解析を行い,麻酔の説明動画の視聴前後でHADS-Aのスコアに有意な差は認めなかったが低下する傾向が見られた。

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2024&ichushi_jid=J01397&link_issn=&doc_id=20240410200016&doc_link_id=%2Fad3msuie%2F2024%2F007304%2F013%2F0278b0285%26dl%3D3&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fad3msuie%2F2024%2F007304%2F013%2F0278b0285%26dl%3D3&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_4.gif

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BACKGROUND: Poor glycemic control may be a risk factor for hypoglycemia in terminally ill patients with cancer with a history of diabetes mellitus (DM). However, no guidelines have been established for achieving glycemic control in this patient population, and epidemiological information remains lacking. OBJECTIVES: We aimed to investigate the prevalence of hypoglycemic episodes and provide epidemiological information on hypoglycemia in terminally ill patients with cancer with a history of DM admitted to a general ward. DESIGN: This was a single-center, retrospective, observational study. SETTING/SUBJECTS: This study enrolled terminally ill patients with cancer with a history of DM, receiving palliative care at a hospital in Japan between January 2017 and July 2022. MEASUREMENTS: Data extracted from the patients' medical records were age, sex, body mass index, primary cancer, liver metastases, dialysis status, Eastern Cooperative Oncology Group performance status score, type and duration of DM, HbA1c level, and use of diabetes medications (antihyperglycemic agents and types and insulin) at the time of initial visit within 180 days of death. RESULTS: Among the 104 patients included in the analysis, hypoglycemic episodes occurred in 36 patients (34.6%). The total number of hypoglycemic episodes was 132, and the median number of hypoglycemic episodes for each patient during hospitalization was 2.5 (interquartile range, 1-6). CONCLUSIONS: The prevalence of hypoglycemia in terminally ill patients with cancer with a history of DM who were admitted to a Japanese general ward was 34.6%. Further studies are needed to determine the frequency of hypoglycemia because of overtreatment in this patient population.

DOI： 10.1089/pmr.2024.0008

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Acute kidney injury (AKI) after cardiac surgery is a common complication that can lead to death. We previously reported that the creatinine reduction ratio (CRR) serves as a useful prognostic factor for AKI. The primary objective of this study was to determine the predictors of AKI after surgery. The secondary objective was to determine the reliability of the CRR for short- and long-term outcomes. We retrospectively collected information about cardiac surgery patients who underwent cardiopulmonary bypass. Patients were divided into AKI and non-AKI groups based on the AKIN and RIFLE criteria. We analyzed the two groups regarding the preoperative patient data and operative information. The CRR was calculated as follows: (preoperative creatinine-postoperative creatinine)/preoperative creatinine. The prognostic factors of AKI-CS were surgery time, CPB time, aorta clamp time, platelet transfusion, and CRR < 20%. In the multivariate logistical analysis, CRR was an independent predictor of AKI (adjusted odds ratio: 0.90 [0.87-0.93], p < 0.001). However, there were no significant differences in CRR in terms of the rate of new onset chronic kidney disease (CKD). After cardiac surgery with cardiopulmonary bypass, CRR has good diagnostic power for predicting perioperative AKI. However, we cannot use it as a prognostic factor over a long-term period.

DOI： 10.3390/jcm13010009

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Language：Japanese   Publisher：克誠堂出版(株)  

＜文献概要＞63歳,男性。尿路感染による敗血症性ショックと,二次性の虚血性心疾患に伴う心原性ショックの合併が疑われた。敗血症性ショックに対する感染源コントロールと,虚血性心疾患に対する冠動脈カテーテル検査のどちらを優先するかについて緊急で泌尿器科医と循環器内科医とで協議した。冠動脈造影検査に引き続く冠動脈インターベンション,大動脈内バルーンパンピング留置をまず行い,そのあとに手術室で尿管ステントを留置した。各診療科と連携し,治療の優先順位を迅速に決定することで救命できた症例であった。

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2023&ichushi_jid=J01397&link_issn=&doc_id=20231128090014&doc_link_id=10.18916%2Fmasui.2023120011&url=https%3A%2F%2Fdoi.org%2F10.18916%2Fmasui.2023120011&type=%E5%8C%BB%E6%9B%B8.jp_%E3%82%AA%E3%83%BC%E3%83%AB%E3%82%A2%E3%82%AF%E3%82%BB%E3%82%B9&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00024_2.gif

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AIMS: Protein kinase D (PKD), once considered an effector of protein kinase C (PKC), now plays many pathophysiological roles in various tissues. However, little is known about role of PKD in vascular function. We investigated the role of PKD in contraction of rat aorta and human aortic smooth muscle cells (HASMCs) and in haemodynamics in rats. METHODS AND RESULTS: Isometric tension of rat aortic was measured to examine norepinephrine-induced contraction in the presence of PKD, PKC and Rho-kinase inhibitors. Phosphorylation of PKD1, myosin targeting subunit-1 (MYPT1), myosin light chain (MLC), CPI-17 and heat-shock protein 27 (HSP27), and actin polymerization were measured in the aorta. Phosphorylation of MYPT1 and MLC was also measured in HASMCs knocked down with specific siRNAs of PKD 1, 2 and 3. Intracellular calcium concentrations and cell shortening were measured in HASMCs. Norepinephrine-induced aortic contraction was accompanied by increased phosphorylation of PKD1, MYPT1 and MLC and actin polymerization, all of which were attenuated with PKD inhibitor CRT0066101. PKD1 phosphorylation was not inhibited by PKC inhibitor, chelerythrine or Rho kinase inhibitor, fasudil. In HASMCs, the phosphorylation of MYPT1 and MLC was attenuated by PKD1, but not PKD2, 3 knockdown. In HASMCs, CRT0066101 inhibited norepinephrine-induced cell shortening without affecting calcium concentration. Administration of CRT0066101 decreased systemic vascular resistance and blood pressure without affecting cardiac output in rats. CONCLUSIONS: PKD1 may play roles in aorta contraction and haemodynamics via phosphorylation of MYPT1 and actin polymerization in a calcium-independent manner.

DOI： 10.1016/j.mvr.2023.104627

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PURPOSE: To elucidate the postgraduation situation of those who have completed a perianesthesia nurse (PAN) educational course offered in master's degree programs in Japan. DESIGN: This cross-sectional study used an anonymous self-administered questionnaire. METHODS: Of the 42 individuals who completed a PAN educational course offered in master's degree programs in Japan by March 2021, 41 were targeted, excluding the author of this study. The questionnaire was distributed by mail between November 20, 2021, and January 14, 2022, and the participants were asked to return the completed questionnaire by mail. Those working as PANs were asked about their work content, work satisfaction, and thoughts on their prospects in the perianesthesia nursing field. Those not working as a PAN were asked about their future intentions to do so. FINDINGS: The response rate was 95.1% (39/41). PANs are involved in various perianesthesia tasks, and there were no respondents who answered "No" to the question of whether they were glad to have become a PAN. However, of those working as PANs, only 16 (53.3%) indicated that they would like to continue working in that role. Few respondents (n = 3; 10.0%) considered future PAN prospects to be "good," while eight (26.7%) respondents answered "poor," and many (n = 19; 63.3%) stated "neither." CONCLUSIONS: Under the current situation, PANs in Japan do not necessarily have a positive outlook for the future, the causes for which must be analyzed to make the necessary improvements.

DOI： 10.1016/j.jopan.2023.08.001

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Remote ischemic preconditioning (RIPC) protects organs from ischemia-reperfusion injury. Recent trials showed that RIPC improved gas exchange in patients undergoing lung or cardiac surgery. We performed a systematic search to identify randomized controlled trials involving RIPC in surgery under general anesthesia. The primary outcome was the PaO2/FIO2 (P/F) ratio at 24 h after surgery. Secondary outcomes were A-a DO2, the respiratory index, duration of postoperative mechanical ventilation (MV), incidence of acute respiratory distress syndrome (ARDS), and serum cytokine levels. The analyses included 71 trials comprising 7854 patients. Patients with RIPC showed higher P/F ratio than controls (mean difference [MD] 36.6, 95% confidence interval (CI) 12.8 to 60.4, I2 = 69%). The cause of heterogeneity was not identified by the subgroup analysis. Similarly, A-a DO2 (MD 15.2, 95% CI - 29.7 to - 0.6, I2 = 87%) and respiratory index (MD - 0.17, 95% CI - 0.34 to - 0.01, I2 = 94%) were lower in the RIPC group. Additionally, the RIPC group was weaned from MV earlier (MD - 0.9 h, 95% CI - 1.4 to - 0.4, I2 = 78%). Furthermore, the incidence of ARDS was lower in the RIPC group (relative risk 0.73, 95% CI 0.60 to 0.89, I2 = 0%). Serum TNFα was lower in the RIPC group (SMD - 0.6, 95%CI - 1.0 to - 0.3 I2 = 87%). No significant difference was observed in interleukin-6, 8 and 10. Our meta-analysis suggested that RIPC improved oxygenation after surgery under general anesthesia.Clinical trial number: This study protocol was registered in the University Hospital Medical Information Network (registration number: UMIN000030918), https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035305.

DOI： 10.1038/s41598-023-44833-w

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PURPOSE: Non-contact continuous respiratory rate monitoring is preferred for early detection of patient deterioration. However, this technique is under development; a gold standard respiratory monitor has not been established. Therefore, this prospective observational method comparison study aimed to compare the measurement accuracy of a non-contact continuous respiratory rate monitor, a microwave Doppler sensor positioned beneath the mattress, with that of other monitors. METHODS: The respiratory rate of intensive care unit patients was simultaneously measured using a microwave Doppler sensor, capnography, thoracic impedance pneumography, and a piezoelectric sensor beneath the mattress. Bias and 95% limits of agreement between the respiratory rate measured using capnography (standard reference) and that measured using the other three methods were calculated using Bland-Altman analysis for repeated measures. Clarke error grid (CEG) analysis evaluated the sensor's ability to assist in correct clinical decision-making. RESULTS: Eighteen participants were included, and 2,307 data points were analyzed. The bias values (95% limits of agreement) of the microwave Doppler sensor, thoracic impedance pneumography, and piezoelectric sensor were 0.2 (- 4.8 to 5.2), 1.5 (- 4.4 to 7.4), and 0.4 (- 4.0 to 4.8) breaths per minute, respectively. Clinical decisions evaluated using CEG analyses were correct 98.1% of the time for the microwave Doppler sensor, which was similar to the performance of the other devices. CONCLUSION: The microwave Doppler sensor had a small bias but relatively low precision, similar to other devices. In CEG analyses, the risk of each monitor leading to inadequate clinical decision-making was low. TRIAL REGISTRATION NUMBER: UMIN000038900, February 1, 2020.

DOI： 10.1007/s10877-023-01081-7

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DOI： 10.1016/j.burnso.2023.09.001

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BACKGROUND: Diaphragmatic dysfunction often occurs after adult cardiovascular surgery. The prognostic effect of diaphragmatic dysfunction on ventilatory management in patients after cardiovascular surgery is unknown. This study aimed to investigate the association between diaphragmatic dysfunction and prognosis of ventilatory management in adult postoperative cardiovascular surgery patients. METHODS: This study was a single-center retrospective cohort study conducted at a tertiary care university hospital. This study included adult patients admitted to the intensive care unit under tracheal intubation after cardiovascular surgery. Spontaneous breathing trial was performed, and bilateral diaphragmatic motion was assessed using ultrasonography; diaphragmatic dysfunction was classified as normal, incomplete dysfunction, or complete dysfunction. The primary outcome was weaning off in mechanical ventilation. The duration of mechanical ventilation was defined as duration from the date of ICU admission to the date of weaning off in mechanical ventilation. The secondary outcomes were reintubation, death from all causes, improvement of diaphragm position assessed by chest radiographs. The subdistribution hazard ratio or hazard ratio (HR) with 95% confidence of intervals (CIs) were estimated by Fine-Gray models or Cox proportional hazard models adjusted for potential confounders. RESULTS: Of 153 patients analyzed, 49 patients (32.0%) had diaphragmatic dysfunction. Diaphragmatic dysfunction consisted of incomplete dysfunction in 38 patients and complete dysfunction in 11 patients. Diaphragmatic dysfunction groups had longer duration of mechanical ventilation (68 h [interquartile range (IQR) 39-114] vs 23 h [15-67], adjusted subdistribution HR 0.63, 95% CIs 0.43-0.92). There was a higher rate of reintubation (12.2% vs 2.9%, univariate logistic regression analysis p = 0.034, unadjusted odds ratio = 4.70, 95% CIs 1.12-19.65), and a tendency to have higher death from all causes in the diaphragmatic dysfunction group during follow-up period (maximum 6.5 years) (18.4% vs 9.6%, adjusted HR 1.64, 95% CIs 0.59-4.53). The time to improvement of diaphragm position on chest radiograph was significantly longer in the diaphragmatic dysfunction group (14 days [IQR 6-29] vs 5 days [IQR 2-10], adjusted subdistribution HR 0.54, 95% CIs 0.38-0.77). CONCLUSIONS: Diaphragmatic dysfunction after adult cardiovascular surgery was significantly associated with longer duration of mechanical ventilation and higher reintubation.

DOI： 10.1186/s40560-023-00688-x

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Language：Japanese   Publisher：(一社)日本てんかん学会  

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PURPOSE: Tumors can be visualized using 5-Aminolevulinic acid hydrochloride (5-ALA) during transurethral resection of bladder tumors (TURBT). Hypotension is an adverse effect of 5-ALA; however, its incidence and morbidity rates are unknown. This study aimed to describe the incidence of perioperative hypotension and identify risk factors for hypotension among patients after 5-ALA administration in TURBT. METHODS: This retrospective multicenter cohort study was conducted at three general hospitals in Japan. Adult patients who underwent elective TURBT after 5-ALA administration between April 2018 and August 2020 were included. The primary outcome was the incidence of perioperative hypotension (mean blood pressure < 65 mmHg). The secondary outcomes were the use of vasoactive agents and adverse events, including urgent intensive care unit (ICU) admission. Multivariate logistic regression analysis was performed to investigate risk factors of the incidence of intraoperative hypotension. RESULTS: The median age of 261 patients was 73 years. General anesthesia was induced in 252 patients. The intraoperative hypotension was observed in 246 (94.3%) patients. Three patients (1.1%) were urgently admitted to the ICU for continued vasoactive agent use after surgery. All three patients had renal dysfunction. Multivariate logistic regression analysis revealed that general anesthesia was significantly associated with intraoperative hypotension (adjusted odds ratio, 17.94; 95% confidence interval, 3.21-100.81). CONCLUSION: The incidence of hypotension in patients undergoing TURBT after 5-ALA administration was 94.3%. The incidence of urgent ICU admission with prolonged hypotension was 1.1% in all patients with renal dysfunction. General anesthesia was significantly associated with intraoperative hypotension.

DOI： 10.1007/s00540-023-03222-3

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INTRODUCTION: In general, caesarean sections are performed under spinal anaesthesia. Hypotension after spinal anaesthesia adversely affects both the mother and fetus. Although several studies have used pulse oximetry-derived indices, such as pulse perfusion index (PI) and Pleth variability index (PVI), to predict hypotension after spinal anaesthesia, the predictive ability of the PI and PVI remain controversial. METHODS AND ANALYSIS: We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will conduct searches of MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Clinicaltrial.gov, European Union Clinical Trials Register (EU-CTR), WHO International Clinical Trials Registry Platform (ICTRP) and University Hospital Medical Information Network Clinical Trials Registry (UMIN) from inception until 8 October 2022. We will include retrospective and prospective observational studies and randomised controlled trials that evaluated the predictive ability of PI and PVI for hypotension after spinal anaesthesia for caesarean section, published in any language. We will exclude case reports, case series and animal studies. Two authors will independently scan and select eligible studies and perform data extraction and assessment of risk of bias. We will estimate predictive ability of PI and PVI as indices of hypotension after spinal anaesthesia for caesarean section using the Reitsma-type bivariate random-effects synthesis model and the hierarchical summary receiver operating characteristic curve. We will assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required as the systematic review will use existing published data. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022362596.

DOI： 10.1136/bmjopen-2022-069309

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BACKGROUND: Post-pyloric enteral feeding reduces respiratory complications and shortens the duration of mechanical ventilation. Blind placement of post-pyloric enteral feeding tubes (EFT) in patients with critical illnesses is often the first-line method because endoscopy or fluoroscopy cannot be easily performed at bedside; however, difficult placements regularly occur. We reported an association between the stomach position caudal to spinal level L1-L2, evaluated by abdominal radiographs after placement, and difficult placement; however, this method could not indicate difficulty before EFT placement. The aim of our study was to evaluate the association between stomach position, estimated using computed tomography (CT) images taken before the blind placement of the post-pyloric EFT, and the difficulty of EFT placement. METHODS: Data from patients aged ≥ 20 years who underwent post-pyloric EFT in our intensive care unit were obtained retrospectively. Logistic regression analysis was used to evaluate the association between successful initial EFT placement and explanatory variables, including stomach position estimated by CT. Two cut-off values were used: caudal to L1-L2 based on a previous study and the best cut-off value calculated by the receiver operating characteristic curve. Variable selection was performed backward stepwise using Akaike's Information Criterion. RESULTS: Of the total of 453 patients who were enrolled, the success rate of the initial EFT placement was 43.5%. The adjusted odds ratio for successful initial EFT placement of the stomach position caudal to L1-L2 was 0.61 (95% confidence interval: 0.41-1.07). Logistic regression analysis, including the stomach position caudal to L2-L3, calculated as the best cut-off value, indicated that stomach position was an independent factor for failure of initial EFT placement (adjusted odds ratio, 0.55; 95% confidence interval: 0.33-0.91). CONCLUSIONS: Stomach position evaluated using CT images was associated with successful initial post-pyloric EFT placement. The best cut-off value of the greater curvature of the stomach to predict the success or failure of the first attempt was spinal level L2-L3. Trial registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000046986; February 28, 2022). https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000052151.

DOI： 10.1186/s40560-023-00673-4

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PURPOSE: Postoperative sleep disturbances are common. Although several studies have examined the effect of melatonin on postoperative sleep disturbances, the results have not reached any definitive conclusion. We sought to conduct a systematic review to compare the effects of melatonin and melatonin agonists on postoperative sleep quality with those of placebo or no treatment in adult patients who underwent surgery under general or regional anesthesia. METHODS: We searched MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, ClinicalTrials.gov, and the UMIN Clinical Trials Registry up to 18 April 2022. Randomized clinical trials examining the effects of melatonin or melatonin agonists in patients undergoing general or regional anesthesia with sedation for any surgery were eligible for inclusion. The primary outcome was sleep quality measured using a visual analog scale (VAS). The secondary outcomes were postoperative sleep duration, sleepiness, pain, opioid consumption, quality of recovery, and adverse events. A random-effects model was used to combine the results. We assessed study quality with the Cochrane Risk of Bias Tool version 2. We applied a trial sequential analysis to assess the precision of the combined results. RESULTS: Eight studies (516 participants) were analyzed for sleep quality. Of those, four studies used only a short duration of melatonin, either on the night before and the day of surgery or only on the day of surgery. A random-effects meta-analysis showed that melatonin did not improve sleep quality measured by VAS compared with placebo (mean difference, -0.75 mm; 95% confidence interval, -4.86 to 3.35), with low heterogeneity (I2, 5%). Trial sequential analysis revealed that the accrued information size (n = 516) reached the estimated required information size (n = 295). We downgraded the certainty of the evidence because of the high risk of bias. The effect on postoperative adverse events was comparable between the melatonin and control groups. CONCLUSION: Our results indicate that melatonin supplementation does not improve postoperative sleep quality measured with the VAS compared with placebo in adult patients (GRADE: moderate). STUDY REGISTRATION: PROSPERO (CRD42020180167); registered 27 October 2022.

DOI： 10.1007/s12630-023-02442-1

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INTRODUCTION: The celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via the transintervertebral disc approach was the first choice of treatment. The short-term efficacy of this technique has been reported, but the long-term efficacy is not clear. In the present study, we investigated the long-term analgesic efficacy of this technique. METHODS: This multicenter, retrospective, observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via the transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the long-term analgesic efficacy of a one-time NSNB via the transintervertebral disc approach. RESULTS: In total, 76 patients were included in the analysis. The median lowest numerical rating scale (NRS) score was 1 within 14 days. At 1, 2, 3, and 6 months after the nerve block, the median NRS score was also ≤ 2, while the median equivalent oral morphine dose did not show any clinically noticeable increase at those times. CONCLUSION: The long-term analgesic efficacy of NSNB via the transintervertebral disc approach in patients with intractable cancer pain has been demonstrated.

DOI： 10.1007/s40122-023-00506-0

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Publishing type：Research paper (scientific journal)   Publisher：Springer Science and Business Media LLC  

DOI： 10.1007/s12630-023-02442-1

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Other Link： https://link.springer.com/article/10.1007/s12630-023-02442-1/fulltext.html

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BACKGROUND: Hypercalcemia crisis is a rare but severe form of hypercalcemia complicated by multiple organ failure. Hypercalcemia crisis due to hyperparathyroidism is commonly caused by a parathyroid tumor, which often requires surgical resection. However, there are no clear recommendations on when the surgery should be performed. CASE PRESENTATION: A 64-year-old female patient developed hyperparathyroidism due to a parathyroid tumor and hypercalcemic crisis, which was complicated by severe circulatory and respiratory failure refractory to medical therapy, and an emergent surgery was planned to resect the parathyroid tumor. To prevent intraoperative circulatory and respiratory collapse, venoarterial-extra corporeal membrane oxygenation (VA-ECMO) was introduced, resulting in a safe operation and anesthetic management. CONCLUSIONS: In patients with hypercalcemic crisis complicated by severe circulatory and respiratory failure, induction of prophylactic VA-ECMO was useful for safe anesthetic management. Surgical resection should be performed as soon as the diagnosis is made before VA-ECMO is required.

DOI： 10.1186/s40981-023-00606-y

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Language：Japanese   Publisher：(株)シービーアール  

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Language：Japanese   Publisher：(株)シービーアール  

当施設におけるCOVID-19流行期の手術件数の推移を調べ、COVID-19の流行に伴い手術件数が減少した時期について麻酔科医の業務量の変化について検討した。2019年1月から2021年10月までの期間を対象とし、2019年1月から2019年12月までをCOVID-19流行期以前の比較対照期間とした。手術件数が10%以上減少した月は2020年4月、5月(期間1)および2021年7月、8月、9月(期間2)であった。2020年4月、5月、2021年7月、8月、9月の麻酔科医における超過勤務時間の中央値は各々36.5、26.5、35.0、32.0、30.0時間であり、比較対照とした2019年4、5、7、8、9月の超過勤務時間の中央値48.5、40.0、44.0、44.5、36.0時間と比較して有意に減少していた。期間1において手術室の月別平均稼働件数は減少していたが、期間2においては差がなかった。COVID-19の流行により手術件数が減少し、麻酔科医の業務量が減少した時期があった。

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PURPOSE: We examined whether patients' satisfaction improved when patients' preoperative consultations were conducted with perianesthesia nurses (PANs) in collaboration with anesthesiologists, as compared with preoperative consultations conducted by anesthesiologists only. DESIGN: We conducted a study using questionnaires regarding outpatient satisfaction among patients who visited the perioperative management department of Yokohama City University Medical Center between July and December 2018. METHODS: There were 1,595 outpatients during the survey period. After exclusion criteria were applied, we analyzed 590 valid responses. FINDINGS: Regarding the level of understanding, 96.9% of the patients in the nurse-and-anesthesiologist group and 95.6% of the patients in the anesthesiologist-only group answered, "easy to understand," indicating no significant difference. A reduction in concerns, worries, and anxiety was reported by 86.3% of the patients in the nurse-and-anesthesiologist group and 70.4% in the anesthesiologist-only group, indicating a significant difference. Furthermore, 94.1% of the patients in the nurse-and-anesthesiologist group and 87.9% in the anesthesiologist-only group indicated patients' satisfaction with the overall evaluation, indicating another significant difference. A multiple logistic regression analysis was conducted to analyze the anxiety reduction and overall evaluation. We uncovered significant differences in PANs' examinations regarding anxiety reduction and overall evaluation. CONCLUSIONS: Collaboration between anesthesiologists and PANs might be associated with satisfaction and reduced anxiety in preoperative patients without adversely affecting patients' comprehension of anesthesia. Further research is necessary to verify the impacts of PANs' involvement in anesthesia patient care on intra and postoperative patient outcomes and on the cost and efficiency of anesthetic care.

DOI： 10.1016/j.jopan.2022.06.010

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This study aimed to evaluate the effectiveness of acupuncture therapy in preventing emergence agitation (EA) in children. A systematic review and meta-analysis were conducted across multiple locations according to the articles searched. Seven databases, including trial registration sites, were searched. A total of six trials were included involving 489 patients; of them, 244 received acupuncture therapy. Randomized clinical trials (RCTs) evaluating the incidence of EA compared with placebo/sham or standard care in children were included. The primary outcome was the incidence of EA, as evaluated using a specific assessment tool. Data about the incidence rate of EA, heterogeneity, quality of trials and evidence, and adverse events were collected. Additionally, data about patient demographic characteristics, type of anesthesia, duration and onset of acupuncture therapy, EA and pain score, time taken for extubation, and post-anesthesia care unit length of stay were collected. The results indicated that the overall incidence of EA in the acupuncture therapy group and the control group was 23.4% and 39.5%, respectively, with no significant difference (risk ratio, 0.62; 95% confidence interval, 0.26-1.48; I2 = 63%). Subgroup analysis showed a significant difference in the overall incidence of EA in the acupuncture therapy and control groups according to surgery type (high-risk vs. low-risk surgery), suggesting that acupuncture therapy may be effective in reducing EA for patients undergoing high-risk surgery. The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, and possible publication bias. In conclusion, this meta-analysis shows that the currently available RCTs are insufficient to determine the effectiveness of acupuncture therapy in preventing EA in children undergoing general anesthesia.

DOI： 10.1371/journal.pone.0286790

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BACKGROUND: Early warning scores (EWSs) can be easily calculated from physiological indices; however, the extent to which intraoperative EWSs and the corresponding changes are associated with patient prognosis is unknown. In this study, we investigated whether EWS and the corresponding time-related changes are associated with patient outcomes during the anesthetic management of lower gastrointestinal perforation. METHODS: This was a single-center, retrospective cohort study conducted at a tertiary emergency care center. Adult patients who underwent surgery for spontaneous lower gastrointestinal perforations between September 1, 2012, and December 31, 2019, were included. The National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) were calculated based on the intraoperative physiological indices, and the associations with in-hospital death and length of hospital stay were investigated. RESULTS: A total of 101 patients were analyzed. The median age was 70 years, and there were 11 cases of in-hospital death (mortality rate: 10.9%). There was a significant association between the intraoperative maximum NEWS and in-hospital death (odds ratio (OR): 1.60, 95% confidence interval (CI): 1.10-2.32, p=0.013) and change from initial to maximum NEWS (OR: 1.60, 95% CI: 1.07-2.40, p=0.023) in the crude analysis. However, when adjustments were made for confounding factors, no statistically significant associations were found. Other intraoperative EWS values and changes were not significantly associated with the investigated outcomes. The preoperative sepsis-related organ failure assessment score and the intraoperative base excess value were significantly associated with in-hospital death. CONCLUSIONS: No clear association was observed between EWSs and corresponding changes and in-hospital death in cases of lower gastrointestinal perforation. The preoperative sepsis-related organ failure assessment score and intraoperative base excess value were significantly associated with in-hospital death.

DOI： 10.1155/2023/8910198

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PURPOSE: Few reports on opioid withdrawal (OW) due to opioid tapering in cancer patients have been published. The incidence of and risk factors for OW after neurolytic splanchnic nerve block (NSNB) are unknown. This study aimed to elucidate the incidence of and risk factors for OW among cancer patients who could have reduced opioid doses after NSNB. METHODS: This was a multicenter, retrospective, observational study. We reviewed the medical charts of patients who underwent NSNB for intractable cancer pain at four tertiary hospitals in Yokohama City from April 2005 to October 2020. We included patients whose opioid dose was reduced by > 5 mg/day (equivalent oral morphine dose) within 14 days after NSNB. We classified the patients into two groups according to the presence or absence of OW symptoms and compared them. RESULTS: Of the 50 patients who underwent NSNB, 24 were included in the study. OW was observed in five (20.8%) patients. Pain and opioid use duration were significantly longer in OW patients than in non-OW patients (median pain duration 689 vs. 195 days; P < 0.043 and median opioid use duration 486 vs. 136 days; P < 0.030). The opioid tapering dose was significantly larger in patients with OW than in those without OW (median opioid tapering dose 75 vs. 40 mg; P < 0.046). CONCLUSIONS: OW was observed in 20.8% of the patients in the study. A longer pain and opioid use duration and a larger opioid tapering dose may predispose patients to OW.

DOI： 10.1007/s00520-022-07528-y

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INTRODUCTION: Celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. Several guiding techniques such as fluoroscopy, computed tomography, and endoscopy have been devised, and the target of the block has varied in previous studies as both the celiac plexus and splanchnic nerve, which is the main origin of the celiac plexus, have been targeted. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via transintervertebral disc approach is the first choice. However, there have been few reports on the use of this technique. This study investigated the efficacy and safety of this technique. METHODS: This multicenter retrospective observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the clinical success ratio of NSNB, and the secondary outcome was the incidence ratio of NSNB-related adverse events. RESULTS: In total, 103 patients were included in the analysis. Of these, 77 patients met the definition of clinical success, with a ratio of 74.8%. The incidence ratio of NSNB-related adverse events was 40.8% (hypotension, 21.4%; alcohol intoxication, 13.6%; diarrhea, 11.7%; and vascular puncture, 3.9%; duplicates were present). All adverse events improved with observation and symptomatic treatment only. No patient had infection or serious adverse events such as organ or nerve damage. CONCLUSIONS: The clinical success ratio of this technique was 74.8%. Although the incidence of adverse events was 40.8%, all events were mild and no serious adverse events were observed. The findings demonstrate the efficacy and safety of our NSNB in patients with intractable cancer pain.

DOI： 10.1007/s40122-022-00432-7

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Language：Japanese   Publisher：克誠堂出版(株)  

42歳,男性,精巣がんによる上大静脈から左腕頭静脈内の腫瘍塞栓に対し,人工心肺下で腫瘍塞栓摘出術を行った。上半身での中心静脈カテーテル挿入は不可能であり,代替手段として右肘静脈に挿入した末梢静脈圧モニタリングを行い,上半身の脱血を監視した。上大静脈症候群の症状の出現はなく経過し,安全な周術期管理を行うことができた。(著者抄録)

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Language：Japanese   Publisher：日本手術医学会  

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Language：Japanese   Publisher：日本臨床麻酔学会  

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Language：Japanese   Publisher：克誠堂出版(株)  

開腹肝臓切除術後において、一般病棟帰室後に、病状の悪化のために集中治療室に再入室した症例を調査した。対象患者は386名、年齢の中央値は70歳、病棟帰室後の集中治療室再入室は13症例(3.4%)であった。入室理由は出血が最多であった。在院日数は再入室あり群で長期化した。死亡症例(3症例)はすべて再入室症例であった。集中治療室再入室は、開腹肝臓切除術後患者の予後に大きく関連する因子であると考えられた。(著者抄録)

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Other Link： https://search-tp.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2022&ichushi_jid=J01397&link_issn=&doc_id=20220901100010&doc_link_id=%2Fad3msuie%2F2022%2F007109%2F012%2F1008b1012%26dl%3D3&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fad3msuie%2F2022%2F007109%2F012%2F1008b1012%26dl%3D3&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_4.gif

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OBJECTIVES: Excessive tracheal tube cuff pressure can cause postoperative complications; however, the variations in the double-lumen tube cuff pressure in lung surgery have not been investigated. This study aimed to determine the incidence and variations in excess double- lumen tube cuff pressure during one-lung ventilation. DESIGN: A prospective observational study. SETTING: Single secondary-care hospital. PARTICIPANTS: Patients aged ≥18 years scheduled for elective lung surgery using a left-sided double-lumen tube. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Each cuff of the double-lumen tube was connected to a pressure transducer, and the cuff pressure was continuously measured. The excess cuff pressure and its duration (%) were defined as ≥22 mmHg, and the ratio of the duration of excess cuff pressure to the duration of one-lung ventilation, respectively. In total, 147 patients were included in the final analysis. Eighty patients (54.5%) developed cuff pressure elevation in either cuff and 28 patients (19%) in both cuffs. Younger age, male sex, and left-sided surgery were associated with elevated bronchial cuff pressure. Concurrently, younger age, maximal peak inspiratory pressure, and obstructive respiratory dysfunction were associated with an elevated tracheal cuff pressure. A duration of excess cuff pressure >50% in either cuff was found in 34 patients (23%), and both cuffs in 5 patients (3.4%). The correlation between the duration of tracheal and bronchial excess cuff pressure was poor. CONCLUSIONS: A high incidence and long duration of excess tracheal and bronchial cuff pressure were observed during one-lung ventilation for lung surgery.

DOI： 10.1053/j.jvca.2022.06.006

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Language：Japanese   Publisher：克誠堂出版(株)  

22歳の女性で妊娠33週に呼吸困難を伴う肺水腫を契機に、左房心臓腫瘍が診断された。緊急帝王切開を施行後、4日後に心臓腫瘍摘出術を施行した。心臓腫瘍合併妊娠はまれであるが、妊娠経過による循環動態変化に伴って症状は複雑化する。関連各科の意見を統合することで安全な周術期・集中治療管理を行うことができた。(著者抄録)

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Language：Japanese   Publisher：医学図書出版(株)  

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BACKGROUND: During pandemic situations, many guidelines recommend that surgical masks be worn by both healthcare professionals and infected patients in healthcare settings. The purpose of this study was to clarify the levels and changes of oxygen concentration over time while oxygen was administered over a surgical mask. METHODS: Patients scheduled to undergo general anesthesia (n = 99) were enrolled in this study. First, patients were administered oxygen at 6 L/min via an oxygen mask over a surgical mask for 5 min. The patients removed the surgical mask and then took a 3-min break; thereafter, the same amount of oxygen was administered for another 5 min via the oxygen mask. We measured the fraction of inspired oxygen (FiO2), the end-tidal CO2 (EtCO2), and respiratory frequency every minute for 5 min, both while administering oxygen with and without a surgical mask. The FiO2 was measured at the beginning of inspiration and the EtCO2 was measured at the end of expiration. RESULTS: The FiO2 at 5 min was significantly lower when breathing with a surgical mask than that without it (mean difference: 0.08 [95% CI: 0.067-0.10]; p <  0.001). In contrast, the EtCO2 at 5 min was significantly higher when breathing with a surgical mask than that without it (mean difference: 11.9 mmHg [95% CI: 10.9-12.9]; p <  0.001). CONCLUSION: The FiO2 was lower when oxygen was administered over surgical masks than when patients did not wear surgical masks. Oxygen flow may need to be adjusted in moderately ill patients requiring oxygen administration.

DOI： 10.1186/s12871-022-01649-x

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As the proportion of elderly in society increases, so do the number of older patients undergoing surgical procedures. This is concerning as exposure to anesthesia has been identified as a risk factor for Alzheimer's disease (AD). However, the causal relationship between clinical AD development and anesthesia remains conjectural. Preclinical studies have demonstrated that anesthesia, such as halothane, isoflurane, and sevoflurane, induces AD-like pathophysiological changes and cognitive impairments in transgenic mouse models of AD. Desflurane does not have these effects and is expected to have more potential for use in elderly patients, yet little is known about its effects, especially on non-cognitive functions, such as motor and emotional functions. Thus, we examined the postanesthetic effects of desflurane and sevoflurane on motor and emotional function in aged AppNL-G-F/NL-G-F (App-KI) mice. This is a recently developed transgenic mouse model of AD exhibiting amyloid β peptide (Aβ) amyloidosis and a neuroinflammatory response in an age-dependent manner without non-physiological amyloid precursor protein (APP) overexpression. Mice were subjected to a short behavioral test battery consisting of an elevated plus maze, a balance beam test, and a tail suspension test seven days after exposure to 8.0% desflurane for 6 h or 2.8% sevoflurane for 2 h. App-KI mice showed significant increments in the percentage of entry and time spent in open arms in the elevated plus maze, increments in the number of slips and latency to traverse for the balance beam test, increments in the limb clasping score, increments in immobile duration, and decrements in latency to first immobile episode for the tail suspension test compared to age-matched wild type (WT) controls. Desflurane- and sevoflurane-exposed App-KI mice showed a delayed decrement in the number of slips for each trial in the balance beam test, while air-treated App-KI mice rapidly improved their performance, and increased their clasping behavior in the tail suspension test. Furthermore, App-KI inhibited the change in membrane GluA3 following exposure to anesthetics in the cerebellum. These results suggest high validity of App-KI mice as an animal model of AD.

DOI： 10.1186/s13041-022-00910-1

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BACKGROUND: Patients with inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, might present difficulties in achieving postoperative analgesia. Prior studies have suggested that patients with IBD undergoing major abdominal surgery require higher doses of perioperative opioids than do patients without IBD. Considering patients with IBD potentially require high-dose opioids, identifying those requiring higher opioid doses will allow clinicians to optimize the perioperative opioid dose and avoid insufficient pain management or complications of opioid overdose. Therefore, we conducted this study to identify predictive factors that might influence postoperative opioid consumption in patients with IBD. METHODS: This single-center, historical cohort study reviewed the medical records of all patients admitted to the IBD center of our institution for surgery and who used intravenous fentanyl patient-controlled analgesia (PCA) after open abdominal surgery between June 2013 and April 2017. Ultimately, 179 patients were enrolled in the analysis. Variables expected to influence and/or represent pain, analgesia, inflammation, disease condition, and extent of surgery were selected as potential explanatory variables for predicting postoperative opioid consumption. Multivariable linear regression analysis was used to examine the effect of independent variables on postoperative fentanyl consumption. RESULTS: Of the nine predictive variables selected using the stepwise-selection method, eight were significant. Intraoperative fentanyl consumption, current smoking, ulcerative colitis, administration of biologics during the month before surgery, and the use of supplementary analgesics had a significant increasing effect on postoperative fentanyl consumption, whereas droperidol concentration in the PCA solution, age, and diabetes mellitus had a significant decreasing effect. Preoperative use of opioids was a non-significant variable. The adjusted coefficient of determination was 0.302. CONCLUSIONS: Intraoperative fentanyl consumption, current smoking, ulcerative colitis, administration of biologics during the month before surgery, and the use of supplementary analgesics had a significant increasing effect, whereas droperidol concentration in the PCA solution, age, and diabetes mellitus had a significant decreasing effect on postoperative fentanyl consumption. These factors should be considered when adopting postoperative intravenous fentanyl PCA administration for patients with IBD. TRIAL REGISTRATION: Registry: UMIN Clinical Trials Registry. CLINICAL TRIAL NUMBER: UMIN000031198 . Date of registration: February 8, 2018.

DOI： 10.1186/s12871-022-01606-8

PubMed

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Pulmonary hypertension (PH) is a severe and progressive disease that causes elevated right ventricular systolic pressure, right ventricular hypertrophy and ultimately right heart failure. However, the underlying pathophysiologic mechanisms are poorly understood. We previously showed that 3,4-l-dihydroxylphenyalanine (DOPA) sensitizes vasomotor response to sympathetic tone via coupling between the adrenergic receptor alpha1 (ADRA1) and a G protein-coupled receptor 143 (GPR143), a DOPA receptor. We investigated whether DOPA similarly enhances ADRA1-mediated contraction in pulmonary arteries isolated from rats, and whether GPR143 is involved in the PH pathogenesis. Pretreating the isolated pulmonary arteries with DOPA 1 μM enhanced vasoconstriction in response to phenylephrine, an ADRA1 agonist, but not to U-46619, a thromboxane A2 agonist or endothelin-1. We generated Gpr143 gene-deficient (Gpr143-/y) rats, and confirmed that DOPA did not augment phenylephrine-induced contractile response in Gpr143-/y rat pulmonary arteries. We utilized a rat model of monocrotaline (MCT)-induced PH. In the MCT model, the right ventricular systolic pressure was attenuated in the Gpr143-/y rats than in WT rats. Phenylephrine-induced cell migration and proliferation were also suppressed in Gpr143-/y pulmonary artery smooth muscle cells than in WT cells. Our result suggests that GPR143 is involved in the PH pathogenesis in the rat models of PH.

DOI： 10.1016/j.jphs.2021.11.008

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OBJECTIVE: Phase-amplitude coupling between high-frequency (≥150 Hz) and delta (3-4 Hz) oscillations - modulation index (MI) - is a promising, objective biomarker of epileptogenicity. We determined whether sevoflurane anesthesia preferentially enhances this metric within the epileptogenic zone. METHODS: This is an observational study of intraoperative electrocorticography data from 621 electrodes chronically implanted into eight patients with drug-resistant, focal epilepsy. All patients were anesthetized with sevoflurane during resective surgery, which subsequently resulted in seizure control. We classified 'removed' and 'retained' brain sites as epileptogenic and non-epileptogenic, respectively. Mixed model analysis determined which anesthetic stage optimized MI-based classification of epileptogenic sites. RESULTS: MI increased as a function of anesthetic stage, ranging from baseline (i.e., oxygen alone) to 2.0 minimum alveolar concentration (MAC) of sevoflurane, preferentially at sites showing higher initial MI values. This phenomenon was accentuated just prior to sevoflurane reaching 2.0 MAC, at which time, the odds of a site being classified as epileptogenic were enhanced by 86.6 times for every increase of 1.0 MI. CONCLUSIONS: Intraoperative MI best localized the epileptogenic zone immediately before sevoflurane reaching 2.0 MAC in this small cohort of patients. SIGNIFICANCE: Prospective, large cohort studies are warranted to determine whether sevoflurane anesthesia can reduce the need for extraoperative, invasive evaluation.

DOI： 10.1016/j.clinph.2021.11.004

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Publisher：Cold Spring Harbor Laboratory  

Rationale:
Acute respiratory distress syndrome (ARDS) with COVID-19 is aggravated by hyperinflammatory responses even after passing the peak of viral load. However, the underlying mechanisms remain unclear.

Objectives :
Here, we assess whether alveolar epithelial cell necrosis and subsequent releases of damage associated molecular patterns (DAMPs) at an early disease stage aggravate ARDS with COVID-19

Methods:
In patients with COVID-19 with and without ARDS and healthy adults, serum levels of the following were quantified: an epithelial total cell death marker, cytokeratin18-M65; an epithelial apoptosis marker, CK18-M30; HMGB-1; and alveolar epithelial and endothelial injury markers, sRAGE, angiopoietin-2, and surfactant protein-D. Molecular mechanisms of alveolar epithelial cell death and effects of HMGB-1 neutralization on alveolar tissue injury were assessed using a mouse model of COVID-19-induced ARDS.

Measurements and main results:
The levels of CK18-M65, CK18-M30, and alveolar tissue injury markers were elevated in early stages of ARDS. The median M30/M65 ratio, an epithelial apoptosis indicator, was 31.50% in patients with ARDS, a value significantly lower than that of non-ARDS patients or healthy subjects. Serum levels of HMGB-1, one of DAMPs released from necrotic cells, were also significantly elevated in ARDS versus non-ARDS patients. In a COVID-19-induced ARDS mouse model, alveolar epithelial cell necrosis involved two forms of programmed necrosis, necroptosis and pyroptosis. Finally, neutralization of HMGB-1 attenuated alveolar tissue injury in the mouse model.

Conclusions:
Necrosis, including necroptosis and pyroptosis, seems to be the primary form of alveolar epithelial cell death, and subsequent release of DAMPs is a potential driver of COVID-19-induced ARDS.

DOI： 10.1101/2022.01.23.22269723

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Language：Japanese   Publisher：Japanese Pharmacological Society  

We previously demonstrated that L-DOPA modulated the vascular α1-adrenergic receptor through GPR143, a G-protein coupled receptor, and sensitized vasomotor tone. In this study, we examined a possible role of GPR143 in the pathogeneisis of pulmonary hypertension (PH). In isolated pulmonary arteries, L-DOPA (1 μM) augmented contractile response to phenylephrine, an α1 adrenergic receptor agonist. We generated GPR143 gene-deficient (<i>Gpr143</i>^<i>-/y</i>) rats and comparatively studied the effect of L-DOPA. L-DOPA did not modify phenylephrine-induced response in the pulmonary arteries of <i>Gpr143</i>^<i>-/y</i> rats, thereby indicating that the action of L-DOPA was mediated by GPR143. We next established monocrotaline (MCT, 60 mg/kg) -induced PH model in wild type (WT) and <i>Gpr143</i>^<i>-/y</i> rats. One month after injection subcutaneously with MCT , the right ventricular systolic pressure (RVSP) was attenuated in <i>Gpr143</i>^<i>-/y</i> rats as compared to the WT rats (49.7 +/- 1.1 mmHg and 41.4 +/- 1.4 mmHg in WT and <i>Gpr143</i>^<i>-/y</i>, p&lt;0.05, N=5). Coordinately, the right ventricle to body weight (RV/BW) (5.4 +/- 0.2 × 10^-4 and 4.7 +/- 0.1 × 10^-4 in WT and <i>Gpr143</i>^<i>-/y</i>, p&lt;0.01, N=12) was also reduced in <i>Gpr143</i>^<i>-/y</i> rats compared to the WT rats. Furthermore, in primary cultures of pulmonary artery smooth muscle cells (PASMCs), the proliferative and migratory capacity of <i>Gpr143</i>^<i>-/y</i> PASMCs after phenylephrine treatment was reduced compared to <i>Gpr143</i>-WT PASMCs. We here provide evidence that GPR143 may be involved in MCT-induced PH in rats by affecting the proliferative and migratory capacity of PASMCs.

DOI： 10.1254/jpssuppl.95.0_1-yia-06

CiNii Research

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INTRODUCTION: In geriatric patients, hypotension is often reported after general anesthesia induction using propofol. Remimazolam is a novel short-acting sedative. However, the incidence of hypotension after general anesthesia induction using remimazolam in geriatric patients remains unclear. This study aims to compare the incidence of hypotension associated with remimazolam and propofol in patients aged ≥80 years. METHODS: This single-center, double-blind, randomized, two-arm parallel group, standard treatment-controlled, interventional clinical trial will include 90 patients aged ≥80 years undergoing elective surgery under general anesthesia who will be randomized to receive remimazolam or propofol for induction. The primary outcome is the incidence of hypotension after general anesthesia induction, occurring between the start of drug administration and 3 min after intubation. We define hypotension as mean blood pressure <65 mmHg. The primary outcome will be analyzed using the full analysis set. The incidence of hypotension in the two groups will be compared using the Mantel-Haenszel χ2 test. Subgroup analysis of the primary outcome will be performed based on the Charlson comorbidity index, clinical frailty scale, hypertension in the ward, and age. Secondary outcomes will be analyzed using the Fisher's exact test, Student's t test, and Mann-Whitney U test, as appropriate. Logistic regression analysis will be performed to explore the factors associated with the incidence of hypotension after anesthesia induction. DISCUSSION: Our trial will determine the efficacy of remimazolam in preventing hypotension and provide evidence on the usefulness of remimazolam for ensuring hemodynamic stability during general anesthesia induction in geriatric patients. TRIAL REGISTRATION: The study has been registered with UMIN Clinical Trials Registry (UMIN000042587), on June 30, 2021.

DOI： 10.1371/journal.pone.0275451

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Pain, autonomic distress, and emergence agitation occur commonly in children undergoing general anesthesia. While acupuncture therapy has been reported to effectively reduce such pain and autonomic distress in children, its effect in preventing emergence agitation remains unclear. Therefore, we will conduct a systematic review and meta-analysis with trial sequential analysis to evaluate the effect of acupuncture therapy in preventing emergence agitation in children undergoing general anesthesia. Methods and analysis This protocol was prepared according to the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for Protocols guidelines. We will conduct a search for randomized controlled trials that evaluated the effect of acupuncture therapy in preventing emergence agitation. The following databases will be searched for relevant articles: MEDLINE, CENTRAL, Embase, and Web of Science; four pre-registration sites will be accessed from inception to April 1, 2021. No language restrictions will be applied. Two authors will independently scan and select eligible studies, extract the data, and assess the risk of bias. The incidence of emergence agitation will be combined as a risk ratio with a 95% confidence interval using a random-effect model. The I2 statistics will be used to assess heterogeneity. We will evaluate the quality of the clinical trials using the Cochrane methodology and assess the quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. If appropriate, a trial sequential analysis will be performed. Expected outcomes This meta-analysis will be the first to evaluate the effect of acupuncture therapy in preventing emergence agitation in children. The findings from this meta-analysis have the potential to reveal pivotal factors that affect the clinical effect of acupuncture therapy, thereby supporting the optimization of acupuncture therapy for emergence agitation. Protocol registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000040775).

DOI： 10.1371/journal.pone.0264197

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Publishing type：Research paper (scientific journal)   Publisher：Springer Science and Business Media LLC  

<title>Abstract</title>Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that leads to severe respiratory failure (RF). It is known that host exposure to viral infection triggers an iron-lowering response to mitigate pathogenic load and tissue damage. However, the association between host iron-lowering response and COVID-19 severity is not clear. This two-center observational study of 136 adult hospitalized COVID-19 patients analyzed the association between disease severity and initial serum iron, total iron-binding capacity (TIBC), and transferrin saturation (TSAT) levels. Serum iron levels were significantly lower in patients with mild RF than in the non-RF group; however, there were no significant differences in iron levels between the non-RF and severe RF groups, depicting a U-shaped association between serum iron levels and disease severity. TIBC levels decreased significantly with increasing severity; consequently, TSAT was significantly higher in patients with severe RF than in other patients. Multivariate analysis including only patients with RF adjusted for age and sex demonstrated that higher serum iron and TSAT levels were independently associated with the development of severe RF, indicating that inadequate response to lower serum iron might be an exacerbating factor for COVID-19.

DOI： 10.1038/s41598-021-92921-6

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Other Link： http://www.nature.com/articles/s41598-021-92921-6

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Trans-jejunal nutrition via a post-pyloric enteral feeding tube has a low risk of aspiration or reflux; however, placement of the tube using the blind method can be difficult. Assistive devices, such as fluoroscopy or endoscopy, are useful but may not be suitable for patients with hemodynamic instability or severe respiratory failure. The aim of this study was to explore factors associated with first-pass success in the blind placement of post-pyloric enteral feeding tubes in critically ill patients. METHODS: Data were obtained retrospectively from the medical records of adult patients who had a post-pyloric enteral feeding tube placed in the intensive care unit between January 1, 2012, and December 31, 2018. Logistic regression analysis was performed to assess the association between first-pass success and the independent variables. For logistic regression analysis, the following 13 variables were defined as independent variables: age, sex, height, fluid balance from baseline, use of sedatives, body position during the procedure, use of cardiac assist devices, use of prokinetic agents, presence or absence of intestinal peristalsis, postoperative cardiovascular surgery, use of renal replacement therapy, serum albumin levels, and position of the greater curvature of the stomach in relation to spinal levels L1 - L2. RESULTS: Data obtained from 442 patients were analyzed. The first-pass success rate was 42.8% (n = 189). Logistic regression analysis demonstrated that the position of the greater curvature of the stomach cephalad to L1 - L2 was only associated with successful placement (odds ratio for first-pass success, 0.62; 95% confidence interval: 0.40 - 0.95). CONCLUSIONS: In critically ill patients, the position of the greater curvature of the stomach caudal to L1 - L2 may be associated with a lower first-pass success rate of the blind method for post-pyloric enteral feeding tube placement. Further studies are needed to verify our results because the position of the stomach was estimated by radiographs after enteral feeding tube placement. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN000036549; April 20, 2019).

DOI： 10.1186/s40560-021-00577-1

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

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INTRODUCTION: The circadian rhythm of melatonin secretion is disturbed after general anaesthesia, leading to postoperative sleep disturbance. Small studies investigating the preventive effect of melatonin administration on postoperative sleep disturbance have not reached any conclusions. Therefore, we will conduct a systematic review and meta-analysis to obtain conclusive results. METHODS AND ANALYSIS: We prepared this protocol following the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines. We will conduct a search for randomised controlled trials that evaluated the effect of melatonin and melatonin agonists on postoperative sleep quality in adult patients undergoing general anaesthesia or regional anaesthesia with sedation. We will exclude patients undergoing regional anaesthesia without sedation. Relevant studies will be searched in the following eight databases: MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science and four preregistration sites from inception to 1 January 2021. No language restrictions will be applied. Two authors will independently scan and select eligible studies and perform data extraction and assessment of the risk of bias. The Visual Analogue Scale scores for sleep quality will be combined as the mean difference with a 95% CI using a random-effect model; we will use I2 to assess heterogeneity. We will evaluate the quality of trials using the Cochrane methodology and assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. If appropriate, trial sequential analysis will be performed. ETHICS AND DISSEMINATION: No ethical approval is required for this meta-analysis, as it does not include individual patient data. We will disseminate the results of this meta-analysis in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020180167.

DOI： 10.1136/bmjopen-2020-047858

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publishing type：Research paper (scientific journal)  

Continuous monitoring of the respiratory rate is crucial in an acute care setting. Contact respiratory monitoring modalities such as capnography and thoracic impedance pneumography are prone to artifacts, causing false alarms. Moreover, their cables can restrict patient behavior or interrupt patient care. A microwave Doppler sensor is a novel non-contact continuous respiratory rate monitor. We compared respiratory rate measurements performed with a microwave Doppler sensor mounted on the ceiling of an intensive care unit with those obtained by conventional methods in conscious and spontaneously breathing patients. Participants' respiratory rate was simultaneously measured by visual counting of chest wall movements for 60 s; a microwave Doppler sensor; capnography, using an oxygen mask; and thoracic impedance pneumography, using electrocardiogram electrodes. Bland-Altman analysis for repeated measures was performed to calculate bias and 95% limits of agreement between the respiratory rate measured by visual counting (reference) and that measured by each of the other methods. Among 52 participants, there were 336 (microwave Doppler sensor), 275 (capnography), and 336 (thoracic impedance pneumography) paired respiratory rate data points. Bias (95% limits of agreement) estimates were as follows: microwave Doppler sensor, 0.3 (- 6.1 to 6.8) breaths per minute (bpm); capnography, - 1.3 (- 8.6 to 6.0) bpm; and thoracic impedance pneumography, 0.1 (- 4.4 to 4.7) bpm. Compared to visual counting, the microwave Doppler sensor showed small bias; however, the limits of agreement were similar to those observed in other conventional methods. Our monitor and the conventional ones are not interchangeable with visual counting.Trial registration number: UMIN000032021, March/30/2018.

DOI： 10.1007/s10877-021-00733-w

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BACKGROUND AND OBJECTIVES: Although previous reports have shown intraocular pressure changes during robotic-assisted laparoscopic prostatectomy, they did not discuss the time course of changes or the timing of the largest change. We conducted this study to quantify pressure changes over time in patients assuming the steep Trendelenburg position during robotic-assisted laparoscopic prostatectomy. METHODS: Twenty-one men were enrolled. Intraocular pressure was measured before anesthesia induction in the supine position (T0); 30 (T1), 90 (T2), and 150 minutes after assuming the Trendelenburg position (T3); and 30 minutes after reassuming the supine position (T4). End-tidal carbon dioxide and blood pressure were also recorded. To compare intraocular pressure between the time points, we performed repeated-measures analysis of variance. A mixed-effects multivariate regression analysis was conducted to adjust for confounding factors. RESULTS: The mean (standard deviation) intraocular pressure was 18.3 (2.4), 23.6 (3.0), 25.1 (3.1), 25.3 (2.2), and 18.1 (5.0) mmHg at T0, T1, T2, T3, and T4, respectively. The mean intraocular pressure was higher at T1, T2, and T3 than at T0 (p < 0.0001 for all). There was no significant difference between T0 and T4, and between T3 and T2 (p > 0.99 for both). CONCLUSIONS: The Trendelenburg position during robotic-assisted laparoscopic prostatectomy increased intraocular pressure. The increase was moderate at 90 minutes after the position was assumed, with the value being approximately 7 mmHg higher than the baseline value. The baseline intraocular pressure was restored at 30 minutes after the supine position was reassumed. TRIAL REGISTRATION: UMIN ID 000014973 DATE OF REGISTRATION: August 27, 2014.

DOI： 10.1016/j.bjane.2021.02.041

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Language：Japanese   Publisher：克誠堂出版(株)  

症例は74歳男性で、膵粘液性嚢胞腫瘍に対し、膵頭十二指腸切除術を施行した。抜管は、患者の強い歯の食いしばりなどはなく、円滑に行われた。抜管後、脱落歯の有無を特に意識した口腔内観察は行わなかった。翌朝、術後回診の際に患者本人より右門歯破損の訴えがあり、診察上も歯牙の破損を認めた。破損歯を誤嚥している可能性があるため、胸部および腹部単純X線検査を施行したところ、胃内部に破損歯と思われる異常陰影を認めた。患者の残存門歯の形状から、破損歯の先端は鋭利と予想された。この破損歯が再建した消化管を通過する際に粘膜を損傷する危険性が懸念されたため、内視鏡的に摘出する方針となった。この時点で1度目のX線検査から時間が経過しており、万が一、破損歯が再建部位よりも尾側にある場合には内視鏡下での摘出が困難になるため、再度胸部単純X線検査を施行し、位置を確認した。異常陰影の位置には変化なく、内視鏡下での摘出は可能であると判断され、緊急内視鏡下摘出術が施行された。内視鏡を挿入すると腎内に破損歯を認め、鉗子で容易に回収できた。その際、胃内の破損歯摘出部分やそのほかの上部消化管粘膜にも明らかな出血や粘膜損傷は認められなかった。

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2021&ichushi_jid=J01397&link_issn=&doc_id=20210225240009&doc_link_id=%2Fad3msuie%2F2021%2F007003%2F011%2F0297-0300%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fad3msuie%2F2021%2F007003%2F011%2F0297-0300%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Publisher：Cold Spring Harbor Laboratory  

<title>Abstract</title><sec><title>Objective</title>To evaluate the association between iron metabolism indicators and disease severity in hospitalized patients with coronavirus disease 2019 (COVID-19).

</sec><sec><title>Design</title>Two-center observational study

</sec><sec><title>Setting</title>A university hospital and a core hospital in Yokohama, Japan

</sec><sec><title>Patients</title>Adults with COVID-19 whose serum iron levels were measured within the first 5 days of hospitalization were included. Patients who refused mechanical ventilation were excluded from the study.

</sec><sec><title>Measurements and Main Results</title>One hundred thirty-six patients were included in this study. We analyzed the association between COVID-19 severity and serum iron, total iron binding capacity (TIBC), and transferrin saturation (TSAT) levels. Disease severity was defined as the worst respiratory status during hospitalization. Serum iron levels were significantly lower in patients with mild respiratory failure (RF) (n=55, median serum iron level: 24 [interquartile range: 19–42] mg/dL) than in the non-RF group (n=44, 40 [24–80] mg/dL) and the severe RF group (n=37, 60 [23.5–87] mg/dL); however, there were no significant differences in iron levels between the non-RF and severe RF groups (non-RF <italic>vs</italic>. mild RF: p=0.019, non-RF <italic>vs</italic>. severe RF: p&gt;0.999, and mild RF <italic>vs</italic>. severe RF: p=0.009). That is, there was a U-shaped association between serum iron levels and disease severity. TIBC levels decreased significantly with increasing severity; consequently, TSAT was significantly higher in patients with severe RF than in other patients. Multivariate analysis including only patients with RF adjusted for age and sex demonstrated that higher serum iron or TSAT levels were independently associated with development of severe RF.

</sec><sec><title>Conclusions</title>A U-shaped association between serum iron level and RF severity in hospitalized COVID-19 patients was observed. Higher serum iron levels in COVID-19 patients with RF are associated with the development of severe RF, indicating that inadequate response to lower serum iron might be an exacerbating factor for COVID-19.

</sec>

DOI： 10.1101/2021.02.19.21252061

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Language：English   Publishing type：Research paper (scientific journal)  

To avoid the risk of R-on-T incident and the unnecessary decrease of cardiac output, we devised an algorithm consisting of six steps for choosing the most appropriate intraoperative pacemaker (PM) mode, which is modified from Heart Rhythm Society and the American Society of Anesthesiologists expert consensus statement. Following this algorithm, we reviewed previous operations at our hospital to evaluate the appropriateness of the choices. Six of 78 cases (7.7%) were unfit to the algorithm because of an inappropriate mode change. The PM mode was changed preoperatively in four patients, even though the surgical site was under the umbilicus. In one case of the two other cases, the PM mode was changed from AAI to VOO. This case could not be avoided by the previous algorithm of the expert clinical statements. In another case, the anesthesiologist did not change PM mode even though the patient underwent parotidectomy and his heart rate depended on PM. Prospective research on this algorithm could clarify its usefulness in the future. Moreover, discussions about this algorithm could help develop this field of study and improve the intraoperative management of PMs.

DOI： 10.1007/s00540-020-02878-5

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Publisher：Cold Spring Harbor Laboratory  

The time course and specific contributions of alveolar epithelial and endothelial injury to the pathogenesis of acute respiratory distress syndrome (ARDS) with coronavirus disease (COVID-19) remain unclear. Here, we evaluated the characteristics of circulating markers of alveolar epithelial and endothelial injury in serum samples from eleven ARDS patients and ten non-ARDS patients, all with COVID-19. Our results indicates that the alveolar epithelial injury at the very early disease stage and the endothelial injury which continues to exacerbate during the later disease stage seem to be the hallmarks of ARDS with COVID-19.

DOI： 10.1101/2021.01.10.21249528

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Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVES: To determine the prevalence of neuropathic pain among terminally ill patients with cancer admitted to a general ward, using the International Association for the Study of Pain algorithm. METHODS: This prospective observational study was conducted at a tertiary care center. We enrolled terminally ill patients with cancer admitted to the general ward between September 2018 and September 2019. On the day of consultation with our palliative care team, pain management clinicians examined and diagnosed neuropathic pain using the International Association for the Study of Pain diagnostic criteria. RESULTS: A total of 108 patients were enrolled during the study period. The median age was 69 years (interquartile range [IQR] 58.3-76.8 years), 72 patients (66.7%) were men, and the median survival time was 33 days (IQR 14.3-62 days). Of the 108 patients, 33 (30.6%) had neuropathic pain. Patients with neuropathic pain had more severe pain than those without neuropathic pain. CONCLUSIONS: The prevalence of neuropathic pain in terminally ill patients with cancer admitted to a Japanese general ward was 30.6%. Further studies are warranted to elucidate whether the accurate diagnosis of neuropathic pain can improve pain control and/or patient conditions.

DOI： 10.1177/0300060520987726

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Language：English   Publishing type：Research paper (scientific journal)  

The aim of the present study was to investigate the psychological effects of the COVID-19 outbreak and associated factors on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship. This cross-sectional, survey-based study collected demographic data, mental health measurements, and stress-related questionnaires from workers in 2 hospitals in Yokohama, Japan, from March 23, 2020, to April 6, 2020. The prevalence rates of general psychological distress and event-related distress were assessed using the 12-item General Health Questionnaire (GHQ-12) and the 22-item Impact of Event Scale-Revised (IES-R), respectively. Exploratory factor analysis was conducted on the 26-item stress-related questionnaires. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes for workers both at high- and low-risk for infection of COVID-19. A questionnaire was distributed to 4133 hospital workers, and 2697 (65.3%) valid questionnaires were used for analyses. Overall, 536 (20.0%) were high-risk workers, 944 (35.0%) of all hospital workers showed general distress, and 189 (7.0%) demonstrated event-related distress. Multivariable logistic regression analyses revealed that 'Feeling of being isolated and discriminated' was associated with both the general and event-related distress for both the high- and low-risk workers. In this survey, not only high-risk workers but also low-risk workers in the hospitals admitting COVID-19 patients reported experiencing psychological distress at the beginning of the outbreak.

DOI： 10.1371/journal.pone.0245294

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AIM: This study aimed to examine the association between clinically diagnosed chorioamnionitis and failed conversion of epidural labor analgesia to cesarean delivery anesthesia. METHODS: This retrospective, single-center cohort study, conducted in a university hospital, enrolled term parturients undergoing emergency cesarean section after induction of epidural labor analgesia between September 2015 and May 2019. For the purpose of this study, all cases were re-examined to ensure that they fulfilled the criteria of chorioamnionitis, regardless of the actual indication for cesarean section proposed by obstetricians at the time of application. The primary outcome was failure of conversion of epidural labor analgesia to cesarean delivery anesthesia. Multivariable logistic regression analysis was performed to investigate the association between chorioamnionitis and failure of anesthesia for cesarean section. RESULTS: Among the 180 parturients reviewed, 58 (43.9%) fulfilled the criteria for chorioamnionitis. Failure of epidural conversion in the chorioamnionitis (+) group was significantly higher than in the chorioamnionitis (-) group (46.6% [27/58] vs. 18.9% [14/74], crude odds ratio = 3.7, 95% confidence interval: 1.7-8.3). After adjustment for potential confounders (age, body mass index, multiparity, and duration for epidural labor analgesia), chorioamnionitis was found to be associated with failure of anesthesia for cesarean sections (adjusted odds ratio = 3.6, 95% confidence interval: 1.6-8.4). CONCLUSIONS: Chorioamnionitis is associated with the failed conversion of epidural labor analgesia to cesarean delivery anesthesia.

DOI： 10.1371/journal.pone.0250596

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PURPOSE: Patients undergo dilatation and evacuation for abortion or miscarriage. However, bleeding is sometimes problematic. Despite reports on the association between volatile anesthetics and increased bleeding during the procedure, firm evidence is lacking. Therefore, we conducted a systematic review and meta-analysis to compare the effects of volatile anesthetics and propofol on the amount of bleeding in patients undergoing dilatation and evacuation. METHODS: We conducted a systematic search of four databases, namely PubMed, Embase, Cochrane Central Register of Controlled Trials databases, and Web of Science (Clarivate Analytics), from their respective inception to April 2021. Moreover, we searched two trial registration sites. The inclusion criterion was randomized controlled trials of patients who underwent dilatation and evacuation under general anesthesia using volatile anesthetics or propofol. The primary outcome was the amount of perioperative bleeding. The mean difference of the bleeding was combined using a random-effects model. The I2 statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE. RESULTS: Five studies were included in the systematic review. The amount of bleeding was compared in four studies and was higher in the volatile anesthetic group, with a mean difference of 164.7 ml (95% confidence interval, 43.6 to 285.7; p = 0.04). Heterogeneity was considerable, with an I2 value of 97%. Two studies evaluated the incidence of significant bleeding, which was significantly higher in the volatile anesthetic group (RR, 2.42; 95% confidence interval, 1.04-5.63; p = 0.04). CONCLUSION: Choosing propofol over volatile anesthetics during dilatation and evacuation might reduce bleeding and the incidence of excessive bleeding. However, the quality of the evidence was very low. This necessitates further trials with a low risk of bias. TRIAL REGISTRATION: PROSPERO (CRD42019120873).

DOI： 10.1371/journal.pone.0261494

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Immature neurons dominantly express the Na+-K+-2Cl- cotransporter isoform 1 (NKCC1) rather than the K+-Cl- cotransporter isoform 2 (KCC2). The intracellular chloride ion concentration ([Cl-]i) is higher in immature neurons than in mature neurons; therefore, γ-aminobutyric acid type A (GABAA) receptor activation in immature neurons does not cause chloride ion influx and subsequent hyperpolarization. In our previous work, we found that midazolam, benzodiazepine receptor agonist, causes less sedation in neonatal rats compared to adult rats and that NKCC1 blockade by bumetanide enhances the midazolam-induced sedation in neonatal, but not in adult, rats. These results suggest that GABA receptor activation requires the predominance of KCC2 over NKCC1 to exert sedative effects. In this study, we focused on CLP290, a novel KCC2-selective activator, and found that midazolam administration at 20 mg/kg after oral CLP290 intake significantly prolonged the righting reflex latency even in neonatal rats at postnatal day 7. By contrast, CLP290 alone did not exert sedative effects. Immunohistochemistry showed that midazolam combined with CLP290 decreased the number of phosphorylated cAMP response element-binding protein-positive cells in the cerebral cortex, suggesting that CLP290 reverted the inhibitory effect of midazolam. Moreover, the sedative effect of combined CLP290 and midazolam treatment was inhibited by the administration of the KCC2-selective inhibitor VU0463271, suggesting indirectly that the sedation-promoting effect of CLP290 was mediated by KCC2 activation. To our knowledge, this study is the first report showing the sedation-promoting effect of CLP290 in neonates and providing behavioral and histological evidence that CLP290 reverted the sedative effect of GABAergic drugs through the activation of KCC2. Our data suggest that the clinical application of CLP290 may provide a breakthrough in terms of midazolam-resistant sedation.

DOI： 10.1371/journal.pone.0248113

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Purpose of this prospective, double-blind, parallel-group, placebo-controlled, randomised clinical trial was to confirm our hypothesis that ramelteon has a preventive effect on emergence agitation after general anaesthesia in children. Patients aged 18 to 119 months (ASA physical status 1 or 2), scheduled to undergo tonsillectomy under general anaesthesia, were randomly allocated to the ramelteon or placebo group. Before general anaesthesia induction, patients in the ramelteon group received 0.1 mg kg-1 of ramelteon dissolved in 5 mL of lactose-containing syrup. The patients in the placebo group received the same amount of syrup alone. The Paediatric Anaesthesia Emergence Delirium score was calculated every 5 min after awakening. The primary outcome was the incidence of emergence agitation (Paediatric Anaesthesia Emergence Delirium score ≥ 10). Paediatric Anaesthesia Emergence Delirium scores, post-operative vomiting incidence, pain scores, and adverse events were secondary outcomes. Fifty patients were enrolled. Forty-eight patients were analysed. There was no significant between-group difference in the incidence of emergence agitation (67% in both groups; risk ratio, 1.0; 95% CI 0.67-1.49; P > 0.99) or any of the secondary outcomes. Our results suggest that 0.1 mg kg-1 of ramelteon does not have a preventive effect on emergence agitation after general anaesthesia in children undergoing tonsillectomy.

DOI： 10.1038/s41598-020-79078-4

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DOI： 10.1016/j.jclinane.2020.109878

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Halogenated ethers, such as desflurane, sevoflurane, and isoflurane, are known to exert an array of effects besides sedation. However, the postanesthetic effects of desflurane remain undiscovered as no study has explored these effects systematically. Phenotypic screening using behavioral test batteries is a powerful method to identify such effects. In the present study, we behaviorally phenotyped desflurane-treated mice to investigate postanesthetic effects. We applied comprehensive behavioral test batteries measuring sensorimotor functions, anxiety, depression, sociability, attention, and learning abilities, starting 7 days after anesthesia performed with 8.0% desflurane for 6 h. Although our previous study revealed postanesthetic effects of isoflurane in adult mice, in the current study, desflurane-treated mice exhibited no such effects in any behavioral test. To further examine whether desflurane affect behavior in more early time point, we built up a new additional test battery, which carried out 1 day or 3 days after exposure to desflurane. Mice treated with desflurane 1 day before testing showed more slips than other two groups in the first trial, suggesting mild acute side effects of desflurane on motor coordination. These results suggest the safety of desflurane in clinical settings and imply that postanesthetic effects are unique to each halogenated ether.

DOI： 10.1097/FBP.0000000000000567

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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DOI： 10.1016/j.jclinane.2020.109786

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BACKGROUND: The number of elderly patients undergoing elective as well as emergent cardiac surgery is increasing. Octogenarian and older patients undergoing surgery for acute type A aortic dissection (AAD) have a significantly higher risk of postoperative mortality than younger patients. Hemostasis is difficult in octogenarians with AAD. However, few studies have investigated perioperative blood transfusion volumes and hemostatic conditions in patients undergoing AAD surgery. We retrospectively investigated whether these factors differed between octogenarians and younger patients with AAD. METHODS: The records of 207 patients who underwent emergency surgery for AAD were reviewed between 2008 and 2014. We compared the total volumes of transfused blood components (red blood cell concentrate, fresh frozen plasma, platelets concentrate, and cryoprecipitate), perioperative blood coagulation test results (prothrombin time-international normalized ratio, activated partial thrombin time, and activated coagulation time), and intensive care unit and hospital stay durations between octogenarians (n = 33) and patients < 80 years old (n = 170). RESULTS: A significantly greater volume of red blood cell concentrates was transfused in octogenarians than in patients < 80 years old. Isolated prolonged activated partial thromboplastin time was observed in octogenarian patients. Duration of hospital stays was significantly longer in octogenarians than in patients < 80 years old. CONCLUSIONS: Octogenarians required more red blood cells during surgery for AAD and exhibited isolated APTT prolongation.

DOI： 10.1186/s40981-020-00358-z

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BACKGROUND: Appropriate pain management is essential to improve the postoperative recovery after total hip arthroplasty (THA). Various case reports have indicated that anterior quadratus lumborum block (QLB) provides effective postoperative analgesia in lower limb surgeries. However, few randomized controlled trials have confirmed the efficacy of anterior QLB for lower limb surgeries. The aim of this single-center, double-blind, randomized controlled trial is to confirm the efficacy of anterior QLB for postoperative recovery after THA. METHODS: The participants will be randomly assigned to either the anterior QLB or placebo groups, using a set of random numbers for the allocation sequence. Only pharmacists will be aware of the allocations; other investigators will be blinded until study completion. After induction of general anesthesia, anterior QLB will be performed by using 0.25% levobupivacaine or normal saline. Fentanyl will be administered according to blood pressure change during the surgery. The primary outcome will be the quality of recovery 40 score (QoR-40). Secondary outcomes will include the visual analog scale score of pain intensity at rest and movement, intraoperative and postoperative doses of fentanyl, and incidence of postoperative nausea and vomiting. Statistical analysis will be performed by using the Student's t test, Mann-Whitney U test, and Fisher's exact test as appropriate. A P value of less than 0.05 will be considered statistically significant. DISCUSSION: The results of our study will reveal whether anterior QLB is effective for postoperative recovery after THA. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000032255. Registered on 15 April 2018.

DOI： 10.1186/s13063-020-4090-0

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BACKGROUND: Surgical site infection is a major perioperative issue. The morbidity of surgical site infection is high in major digestive surgery, such as pancreaticoduodenectomy. The comprehensive risk factors, including anesthetic factors, for surgical site infection in pancreaticoduodenectomy are unknown. The aim of this study was to investigate the perioperative and anesthetic risk factors of surgical site infection in pancreaticoduodenectomy. METHODS: This was a retrospective cohort study conducted in a single tertiary care center. A total of 326 consecutive patients who underwent pancreaticoduodenectomy between January 2009 and March 2018 were evaluated. Patients who underwent resection of other organs were excluded. The primary outcome was the incidence of surgical site infection, based on a Clavien-Dindo classification of grade 2 or higher. Multivariable logistic regression analysis was performed to investigate the association between surgical site infection and perioperative and anesthetic factors. RESULTS: Of the 326 patients, 116 (35.6%) were women. The median age was 70 years (interquartile range; 64-75). The median duration of surgery was 10.9 hours (interquartile range; 9.5-12.4). Surgical site infection occurred in 60 patients (18.4%). The multivariable analysis revealed that the use of desflurane as a maintenance anesthetic was associated with a significantly lower risk of surgical site infection than sevoflurane (odds ratio, 0.503; 95% confidence interval [CI], 0.260-0.973). In contrast, the duration of surgery (odds ratio, 1.162; 95% CI, 1.017-1.328), cerebrovascular disease (odds ratio, 3.544; 95% CI, 1.326-9.469), and ischemic heart disease (odds ratio, 10.839; 95% CI, 1.887-62.249) were identified as significant risk factors of surgical site infection. CONCLUSIONS: Desflurane may be better than sevoflurane in preventing surgical site infection in pancreaticoduodenectomy. Cerebrovascular disease and ischemic heart disease are potential newly-identified risk factors of surgical site infection in pancreaticoduodenectomy.

DOI： 10.1371/journal.pone.0240490

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BACKGROUND: Intravenous lidocaine in adults undergoing general anesthesia has been shown to reduce the incidence of postoperative nausea and vomiting (PONV). However, the anti-postoperative vomiting (POV) effect of lidocaine in pediatric patients remains unclear. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of intravenous lidocaine on prevention of POV/PONV. METHODS: Six databases including trial registration sites were searched. Randomized clinical trials evaluating the incidence of POV/PONV after intravenous lidocaine compared with control were included. The primary outcome was the incidence of POV within 24 hours after general anesthesia. The incidence of POV was combined as a risk ratio with 95% confidence interval using a random-effect model. We used the I2 to assess heterogeneity. We evaluated the quality of trials using the Cochrane methodology, and we assessed quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events. RESULTS AND DISCUSSION: Six trials with 849 patients were included, of whom 433 received intravenous lidocaine. Three trials evaluated the incidence of POV, and 3 evaluated the incidence of PONV. The overall incidence of POV within 24 hours after anesthesia was 45.9% in the lidocaine group and 63.4% in the control group (risk ratio, 0.73; 95% confidence interval, 0.53-1.00; I2 = 32%; p = 0.05). The incidence of PONV within 24 hours after anesthesia was 3.73% in the lidocaine group and 4.87% in the control group (RR, 0.76; 95% CI, 0.36-1.59; I2 = 0%; p = 0.47). The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, imprecision, and possible publication bias. CONCLUSION: Our meta-analysis suggests that intravenous lidocaine infusion may reduce the incidence of POV, however, the evidence quality was "very low." Further trials with a low risk of bias are necessary.

DOI： 10.1371/journal.pone.0227904

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BACKGROUND: It is reported that postoperative nausea and vomiting, common general anesthesia complications, may be prevented by perioperative intravenous dextrose administration, but with controversial clinical effectiveness. OBJECTIVE: To evaluate perioperative intravenous dextrose for preventing postoperative nausea and vomiting through a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. DATA SOURCES: MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, clinicaltrials.gov, and the University Hospital Medical Information Network Clinical Trials Registry were searched from inception until 22 June 2019. ELIGIBILITY CRITERIA: Trials investigating intravenous dextrose effects vs. placebos on postoperative nausea and vomiting in patients who underwent general anesthesia. RESULTS: Eleven trials (1,250 patients) were included. All participants were ASA1-2. The nine trials included laparoscopic surgeries, and 92.2% of the participants were women. The timing of dextrose infusion was before, during, and after surgery in three, five, and three trials, respectively. Our results revealed intravenous dextrose administration significantly reduced postoperative nausea, but not vomiting, during early and late postoperative periods (risk ratio [95% confidence interval], early nausea: 0.76 [0.59-0.99], late nausea: 0.65 [0.48-0.89]; early vomiting: 1.00 [0.81-1.25], late vomiting: 0.96 [0.43-2.16]). Evidence quality was downgraded to low because the trial sequential analysis indicated more trials are needed for firm conclusions. CONCLUSIONS: Compared with placebos, perioperative intravenous dextrose administration may decrease postoperative nausea but not vomiting. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (registration number: UMIN000030901).

DOI： 10.1371/journal.pone.0231958

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A high mortality rate is found among septic patients with disseminated intravascular coagulation (DIC). Anticoagulants have been used for treating septic DIC especially in Japanese clinical settings; however, their effectiveness is quite controversial across studies. According to several randomized controlled trials and meta-analyses, antithrombin and recombinant thrombomodulin had no therapeutic benefit in the treatment of sepsis. However, the majority of the previous research did not discuss "septic DIC" but simply "sepsis", and some reviews showed that anticoagulants were benefit only in septic DIC. Although immunothrombosis plays an important role in early host defense, it can lead to DIC and organ failure if dysregulated. Therefore, we advocate anticoagulant therapies might have beneficial effects, but research on optimal patient selection is currently lacking.

DOI： 10.1186/s40560-020-0434-9

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Background: Precise control of tidal volume is one of the keys in limiting ventilator-induced lung injury and ensuring adequate ventilation in mechanically ventilated neonates. The aim of the study was to compare the tidal volume (mVT) measured from the expiratory limb of the ventilator with the actual tidal volume (aVT) that would be delivered to the patient using a lung model to simulate a neonate. Methods: This study was conducted using the ASL5000 lung simulator. Three combinations of parameters were set: resistance (cmH2O/L/sec) and compliance (mL/cmH2O) of 50 and 2 (Group 1), 100 and 1 (Group 2), and 150 and 0.5 (Group 3), respectively. The ASL5000 was connected to each of the ventilators including one anesthesia machine ventilator (Drager Fabius GS) and two ICU ventilators (Servo-i Universal and Evita Infinity V500). Each ventilator was evaluated with a set tidal volume of 30 mL (sVT) and a respiratory rate of 25 breathes/minute in both the volume-controlled ventilation (VCV) and dual-controlled ventilation (DCV) modes. Results: The discrepancies between sVT, mVT and aVT were highest with the Fabius anesthesia machine ventilator and increased in the simulated lung injury groups. When comparing the ICU ventilators, the difference was greater the Servo-i and increased when using the DCV mode and with simulated lung injury. Conclusion: Accurate tidal volumes were achieved only with the Infinity ICU ventilator. This was true regardless of mode of ventilation and even during simulated lung injury.

DOI： 10.2147/MDER.S259760

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Language：Japanese   Publisher：Japanese Pharmacological Society  

We previously demonstrated that L-DOPA modulated the vascular α1-adrenergic receptor through GPR143, a G-protein coupled receptor, and sensitized vasomotor tone. The purpose of this study is to clarify the involvement of GPR143, in pulmonary hypertension (PH). We generated GPR143 gene-deficient (KO) rats and comparatively studied monocrotaline (MCT) -induced PH in wild type (WT) and <i>Gpr143</i>-KO rats. We evaluated the interaction between L-DOPA and adrenergic α1 receptor by contractile force of rat isolated pulmonary arteries. The degree of PH was evaluated by right ventricular systolic pressure (RVSP) and right ventricular to body weight ratio (RV/BW). In isolated pulmonary arteries, L-DOPA ( 1 μM) augmented contractile response to phenylephrine, an α1 adrenergic receptor agonist. One month after injection subcutaneously with MCT (60 mg/kg), the RVSP was attenuated in <i>Gpr143</i>-KO rats as compared to the WT rats (49.7 +/- 1.1 mmHg and 41.1 +/- 1.4 mmHg in WT and <i>Gpr143</i>-KO, p&lt;0.01, N=5). Coordinately, the RV/BW was also reduced in <i>Gpr143</i>-KO rats compared to the WT rats (5.8 +/- 0.3 × 10^-4 and 4.9 +/- 0.2 × 10^-4 in WT and <i>Gpr143</i>-KO, p&lt;0.05, N=7). We here provide evidence that GPR143 is involved in MCT-induced PH in rats. Further studies are needed to elucidate detailed mechanisms.

DOI： 10.1254/jpssuppl.93.0_1-yia-23

CiNii Research

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DOI： 10.1016/j.jcrc.2019.12.020

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PURPOSE: Severe hypotension caused by anesthetic administration for anesthesia induction, which might cause ischemic stroke, myocardial injury, acute kidney injury and postoperative mortality, should be prevented. Anesthesiologists are familiar with ultrasound examination of the internal jugular vein (IJV). This study aimed to clarify whether ultrasonographic IJV evaluation just before induction could predict the occurrence of such hypotension. METHODS: Adult patients undergoing surgery under general anesthesia were enrolled after excluding patients with cardiovascular disease or ASA-PS ≥ III. Ultrasonographic IJV images were recorded in both the supine and 10° Trendelenburg positions immediately before induction. Using these images, IJV area (IJV-A), diameter and change rate with posture were measured. Hypotension during induction was defined as mean BP < 60 mmHg or > 30% decrease from baseline. RESULTS: Hypotension during induction was observed in 37 of 82 patients. IJV-A in the Trendelenburg position was 2.02 ± 0.86 and 1.72 ± 0.68 in the hypotensive and non-hypotensive groups, respectively (P = 0.08). Logistic regression analysis performed using age, use of calcium antagonists, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, baseline mean BP and IJV-A in the Trendelenburg position as variables showed that IJV-A in the Trendelenburg position was an independent predictor of hypotension, with an adjusted odds ratio of 3.11 (95% CI 1.07-9.03, P = 0.04). Area under the curve was 0.595 (95% CI 0.469-0.722) for IJV-A in the Trendelenburg position. CONCLUSION: IJV-A in the Trendelenburg position was an independent predictor of hypotension during induction. Further study is required to examine the diagnostic accuracy of IJV-A as a predictor for hypotension during induction.

DOI： 10.1007/s00540-019-02675-9

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BACKGROUND: Clinical trials regarding the antishivering effect of perioperative magnesium have produced inconsistent results. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of perioperative magnesium on prevention of shivering. METHODS: We searched PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, and 2 registry sites for randomized clinical trials that compared the administration of magnesium to a placebo or no treatment in patients undergoing surgeries. The primary outcome of this meta-analysis was the incidence of shivering. The incidence of shivering was combined as a risk ratio with 95% CI using a random-effect model. The effect of the route of administration was evaluated in a subgroup analysis, and Trial Sequential Analysis with a risk of type 1 error of 5% and power of 90% was performed. The quality of each included trial was evaluated, and the quality of evidence was assessed using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events. RESULTS: Sixty-four trials and 4303 patients (2300 and 2003 patients in magnesium and control groups, respectively) were included. The overall incidence of shivering was 9.9% in the magnesium group and 23.0% in the control group (risk ratio, 0.42; 95% CI, 0.33-0.52). Subgroup analysis revealed that the incidence of shivering was lower with IV (risk ratio, 0.29; 95% CI, 0.29-0.54; Grading of Recommendation Assessment, Development, and Evaluation, moderate), epidural (risk ratio, 0.24; 95% CI, 0.13-0.43; Grading of Recommendation Assessment, Development, and Evaluation, low), and intrathecal administration (risk ratio, 0.64; 95% CI, 0.43-0.96; Grading of Recommendation Assessment, Development, and Evaluation, moderate). Only trials with low risk of bias were included for Trial Sequential Analysis. The Z-cumulative curve for IV magnesium crossed the Trial Sequential Analysis monitoring boundary for benefit even though only 34.9% of the target sample size had been reached. The Z-cumulative curve for epidural or intrathecal administration did not cross the Trial Sequential Analysis monitoring boundary for benefit. No increase in adverse events was reported. CONCLUSIONS: Perioperative IV administration of magnesium effectively reduced shivering and Trial Sequential Analysis suggested that no more trials are required to confirm that IV magnesium effectively reduces shivering.

DOI： 10.1213/ANE.0000000000004024

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Language：Japanese   Publisher：真興交易(株)医書出版部  

【目的】がん患者の入院前待機時期の抑うつ状態は、術後抑うつ状態の危険因子となるか否かを探索することを目的とする。【方法】全身麻酔の手術を受ける初発がん患者を対象とし、入院前待機時期と術後3日目に自記式質問紙調査を行った。抑うつ状態の評価はHospital Anxiety and Depression Scaleを用いた。入院前待機時期と術後3日目の抑うつ状態の関連をロジスティック回帰分析で解析した。【結果】対象者は88名。入院前待機時期に抑うつ状態の者が術後3日目に抑うつ状態となるオッズ比は13.04(95%CI3.90〜43.53)であった。【考察】入院前待機時期の抑うつ状態は、術後抑うつ状態の危険因子であると考えられた。入院前待機時期に術後抑うつ状態に対する予防的介入が行える可能性がある。(著者抄録)

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BioMed Central Ltd.  

Background: Quick and complete recovery of cognitive function after general anesthesia is desirable, particularly for working-age patients. Desflurane is less likely to have long-term effects than older-generation inhalational anesthetics, however, its short-term effects have not been fully investigated. Our objective was to elucidate the short-term effects of desflurane exposure on learning and memory in young adult rats. Methods: Seven-week old male Sprague-Dawley rats were exposed to air (control), or desflurane at 0.7 or 1.2 minimum alveolar concentration (MAC) for 2 h (day 0). The inhibitory avoidance (IA) test was performed on day 1 to delineate the effects on contextual learning. Separate groups of control and 1.2 MAC desflurane animals underwent the IA test on days 3 and 7 to examine the time-dependent changes. Because the IA test is known to be dependent on the long-term potentiation (LTP) of the hippocampus and the trafficking of the GluR1 subunit of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor into the synapses, the effects of 1.2 MAC desflurane on these phenomena were evaluated on day 1. Results: Desflurane at 1.2 MAC, but not 0.7 MAC, significantly decreased the IA latencies on day 1 compared with the control (one-way ANOVA, F [2,48] = 5.974, P = 0.005, post hoc Tukey's, mean difference [95% confidence interval], control vs. 1.2 MAC, 168 [49.9 to 287], P = 0.004
control vs. 0.7 MAC, 67.5 [- 51.2 to 186], P = 0.362). The latencies were not affected on days 3 and 7 (day 3, control vs. desflurane, P = 0.861
day 7, control vs. desflurane, P &gt
0.999). Consistently, hippocampal LTP on day 1 was significantly suppressed in the desflurane group compared with the control group (P = 0.006). Moreover, immunoblotting analysis of synaptic GluR1 expression revealed that desflurane exposure significantly suppressed GluR1 delivery to the synapses after IA training. Conclusion: Exposure to a relatively high concentration of desflurane caused reversible learning and memory impairment in young adult rats associated with suppression of GluR1 delivery to the synapses in the hippocampus.

DOI： 10.1186/s12871-019-0793-8

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Alveolar epithelial cell (AEC) death, which is classified as apoptosis or necrosis, plays a critical role in the pathogenesis of acute respiratory distress syndrome (ARDS). In addition to apoptosis, some types of necrosis are known to be molecularly regulated, and both apoptosis and necrosis can be therapeutic targets for diseases. However, the relative contribution of apoptosis and necrosis to AEC death during ARDS has not been elucidated. Here, we evaluated which type of AEC death is dominant and whether regulated necrosis is involved in lipopolysaccharide (LPS)-induced lung injury, an experimental ARDS model. In the bronchoalveolar lavage fluid from the LPS-induced lung injury mice, both the levels of cytokeratin 18-M65 antigen (a marker of total epithelial cell death) and cytokeratin 18-M30 antigen (an epithelial apoptosis marker) were increased. The M30/M65 ratio, which is an indicator of the proportion of apoptosis to total epithelial cell death, was significantly lower than that in healthy controls. In addition, the number of propidium iodide-positive, membrane-disrupted cells was significantly higher than the number of TUNEL-positive apoptotic cells in the lung sections of lung injury mice. Activated neutrophils seemed to mediate AEC death. Finally, we demonstrated that necroptosis, a regulated necrosis pathway, is involved in AEC death during LPS-induced lung injury. These results indicate that necrosis including necroptosis, rather than apoptosis, is the dominant type of AEC death in LPS-induced lung injury. Although further studies investigating human ARDS subjects are necessary, targeting necrosis including its regulated forms might represent a more efficient approach to protecting the alveolar epithelial barrier during ARDS.

DOI： 10.1097/SHK.0000000000001425

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Language：Japanese   Publisher：日本手術医学会  

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BACKGROUND: Supraglottic airway devices are commonly used in general anaesthesia in children. The AuraGain is a newly developed disposable second-generation supraglottic airway device with an inflatable cuff and a gastric port. OBJECTIVE: To confirm our hypothesis that the oropharyngeal leak pressure (OLP) of the AuraGain would be noninferior to that of the i-gel in paediatric patients. DESIGN: A single-blinded, randomised, noninferiority, clinical trial. SETTING: Single-centre trial from January to March 2017. PATIENTS: One hundred paediatric patients (American Society of Anesthesiologists' physical status 1 to 3), aged up to 12 years old, and body weight of 5 to 30 kg requiring a supraglottic airway for elective surgery with an expected surgery time of less than 2 h under general anaesthesia. INTERVENTION: The patients were randomised to allocation to the AuraGain group or the i-gel group. The device size (1.5 to 2.5) used in each group was based on the manufacturer's recommendation. MAIN OUTCOME MEASURES: The primary outcome measure was OLP immediately after insertion, with a predefined noninferiority margin of 3 cmH2O. RESULTS: The OLP immediately after insertion was lower for the AuraGain than for the i-gel (17.1 vs. 23.0 cmH2O; mean difference: -5.9 cmH2O; 95% confidence interval: -8.5 to -3.3 cmH2O; P = 0.98 and <0.001 for noninferiority and superiority, respectively). The first-attempt success rate (AuraGain, 96% vs. i-gel, 90%; P = 0.44) was comparable between the devices. The incidence of blood staining was lower (AuraGain, 6% vs. i-gel, 0%; P = 0.012) and time to insertion was shorter (AuraGain 21.3 vs. i-gel, 17.1 s; P < 0.001) for the i-gel compared with the AuraGain. CONCLUSION: Our noninferiority hypothesis was not adopted. The OLP of the i-gel may be higher than that of the AuraGain, but this superiority hypothesis should be investigated in future trials. The i-gel demonstrated a shorter time to successful placement and lower incidence of blood staining than the AuraGain. TRIAL REGISTRATION: University Hospital Medical Information Network identifier, UMIN000024222.

DOI： 10.1097/EJA.0000000000000987

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DOI： 10.1016/j.bja.2019.01.014

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Language：English  

Bilateral quadratus lumborum blockade (QLB) using ultrasound guidance has been introduced as an abdominal truncal block to improve postoperative analgesia and quality of recovery (QoR) after abdominal surgery, but efficacy remains controversial. The primary aim of this study was to evaluate the efficacy of posterior QLB on the postoperative QoR, and secondarily to evaluate postoperative pain after gynaecological laparoscopic surgery (LS). This study was a single-centre randomized controlled trial. QLB group patients underwent bilateral posterior quadratus lumborum injections with 25-30 mL of 0.25% levobupivacaine after induction of general anaesthesia; the control group underwent no block. Both groups were administered fentanyl-based intravenous patient-controlled analgesia postoperatively. The postoperative QoR was measured using the Quality of Recovery 40 (QoR-40) questionnaire score; postoperative pain was evaluated using the visual analogue scale (VAS) and the cumulative postoperative fentanyl dose. Thirty-one and 29 patients were randomised to the QLB and control groups, respectively. The intraoperative remifentanil dosage was significantly less in the QLB group. The median (interquartile range) for the QoR-40 score was not different between the groups: 154 (133-168) in the QLB group and 158 (144-172) in the control group. There were no statistically significant differences in secondary outcome variables. Single-shot QLB did not improve the QoR or postoperative pain in patients managed by multimodal analgesia after gynaecological LS.

DOI： 10.1177/0310057X19838765

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Language：Japanese   Publisher：(公大)横浜市立大学医学部看護学科  

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2019&ichushi_jid=J05163&link_issn=&doc_id=20190408440006&doc_link_id=1900106&url=https%3A%2F%2Fkango-sakuin.nurse.or.jp%2Fnid%2F1900106&type=%8D%C5%90V%8A%C5%8C%EC%8D%F5%88%F8Web&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00014_1.gif

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Endotracheal tubes used for neonates are not as resistant to breathing as originally anticipated; therefore, spontaneous breathing trials (SBTs) with continuous positive airway pressure (CPAP), without pressure support (PS), are recommended. However, PS extubation criteria have predetermined pressure values for each endotracheal tube diameter (PS 10 cmH2O with 3.0- and 3.5-mm tubes or PS 8 cmH2O with 4.0-mm tubes). This study aimed to assess the validity of these SBT criteria for neonates, using an artificial lung simulator, ASL 5000™ lung simulator, and a SERVO-i Universal™ ventilator (minute volume, 240-360 mL/kg/min; tidal volume, 30 mL; respiratory rate, 24-36/min; lung compliance, 0.5 mL/cmH2O/kg; resistance, 40 cmH2O/L/s) in an intensive care unit. We simulated a spontaneous breathing test in a 3-kg neonate after cardiac surgery with 3.0-3.5-mm endotracheal tubes. We measured the work of breathing (WOB), trigger work, and parameters of pressure support ventilation (PSV), T-piece breathing, or ASL 5000™ alone. RESULTS: WOB displayed respiratory rate dependency under intubation. PS compensating tube resistance fluctuated with respiratory rate. At a respiratory rate of 24/min, the endotracheal tube did not greatly influence WOB under PSV and the regression line of WOB converged with the WOB of ASL 5000™ alone under PS 1 cmH2O; however, at 36/min, endotracheal tube was resistant to breathing under PSV because trigger work increased exponentially with PS ≤ 9 cmH2O. The regression line of WOB under PSV converged with the WOB of T-piece breathing under PS 1 cmH2O. Furthermore, PS compensating endotracheal tube resistance was 6 cmH2O. The WOB of ASL 5000™ alone approached that of respiratory distress syndrome (RDS); however, the pressure of patient effort was normal physiological range at PS 10 cmH2O. PS equalizing WOB under PSV with that after extubation depended on the respiratory rate and upper airway resistance. If WOB after extubation equaled that of T-piece breathing, the PS was 0 cmH2O regardless of the respiratory rates. If WOB after extubation approximated  to that of ASL 5000™ alone, the PS depended on the respiratory rate. CONCLUSION: SBT strategies should be selected per neonatal respiratory rates and upper airway resistance.

DOI： 10.1186/s40635-019-0223-8

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DOI： 10.1213/ANE.0000000000004024

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Language：English  

BACKGROUND: ClearSight is a noninvasive arterial blood pressure monitor, but it remains unknown whether it is affected by the state of perfusion to the fingers. We investigated whether the lower perfusion index (PI) measured with a pulse oximeter, which reflects finger perfusion, would affect the agreement between arterial pressures measured with ClearSight versus those obtained with an arterial catheter. METHODS: Paired arterial pressure data (ClearSight and arterial catheter-based pressures) and PI values were prospectively obtained from 30 patients undergoing major abdominal surgery. The primary outcome was standard deviation (SD) of the bias (precision) of blood pressure between ClearSight and arterial catheter. The ratio of the adjusted SD of the bias between PI≤1 and PI>1 was calculated using the linear mixed-effects model. The secondary outcomes were the bias and the limits of agreement (LOA) between the two devices (repeated measures Bland-Altman analysis). RESULTS: We analyzed 6312 paired data points. The adjusted SD of bias in PI ≤1 compared with those in PI >1 was 1.4-fold (95% confidence interval: 1.3- to 1.4-fold) for systolic arterial pressure, 1.5-fold (95% confidence interval: 1.3- to 1.6-fold) for diastolic arterial pressure, and 1.3-fold (95% confidence interval: 1.2- to 1.5-fold) for mean arterial pressure. The bias (LOA) were as follows: systolic arterial pressure in the PI ≤1 and PI >1 groups, -3.5 (-35.4 to 28.4) mmHg and 2.2 (-19.9 to 24.3) mmHg, respectively; diastolic arterial pressure in the PI ≤1 and PI >1 groups, 13.1 (-5.1 to 31.3) mmHg and 9.0, (-2.6 to 20.6) mmHg, respectively; and mean arterial pressure in the PI ≤1 and PI >1 groups, 8.7 (-11.3 to 28.7) mmHg and 7.6 (-6.2 to 21.3) mmHg, respectively. CONCLUSIONS: PI ≤1 was associated with a large SD of the bias between the devices. The PI value could be a real-time indicator of ClearSight precision.

DOI： 10.1371/journal.pone.0219511

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Kokuseido Publishing Co. Ltd  

A 23-year-old woman developed hypertensive crisis three months previously, and was diagnosed as retroperitoneal massive paraganglioma (extra-adrenal pheo-chromocytoma), with a diameter of 77 mm. Preoperative echocardiography revealed normal cardiac function. The open abdominal surgery might include major vascular surgery because the tumor might have infiltrated into the inferior vena cava and abdominal aorta Therefore, in order to discuss the operative procedure, we held a conference with surgeons in gastroenterology and cardiovascular surgery, nurses and clinical engineers. The surgery was performed under general anesthesia. The tumor did not invade surrounding structures, and simple resection was done. During manipulation of the tumor the patient developed hypertension and tachycardia Severe hypotension (75/ 30 mmHg) followed the resection of the tumor. In addi- tion to volume replacement noradrenaline was administered, but the systolic blood pressure rose only to 80 mmHg In order to treat vasodilatory shock, we started arginine vasopressin infusion at 5 units · hr -1 . Her systolic blood pressure rose to 120 mmHg and was stabilized. The patient was transferred to the intensive care unit (ICU) postoperatively. Her general condition was favorable, and was discharged from the ICU on postoperative day 2. In conclusioa multidisciplinary approach was useful for the perioperative management for resection of massive paraganglioma and arginine vasopressin was effective for refractory hypotension after resection of the tumor.

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Language：Japanese   Publisher：克誠堂出版(株)  

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: The open lung approach (OLA) reportedly has lung-protective effects against acute respiratory distress syndrome (ARDS). Recently, lowering of the driving pressure (ΔP), rather than improvement in lung aeration per se, has come to be considered as the primary lung-protective mechanism of OLA. However, the driving pressure-independent protective effects of OLA have never been evaluated in experimental studies. We here evaluated whether OLA shows protective effects against experimental ARDS even when the ΔP is not lowered. METHODS: Lipopolysaccharide was intratracheally administered to rats to establish experimental ARDS. After 24 h, rats were mechanically ventilated and randomly allocated to the OLA or control group. In the OLA group, 5 cmH2O positive end-expiratory pressure (PEEP) and recruitment maneuver (RM) were applied. Neither PEEP nor RM was applied to the rats in the control group. Dynamic ΔP was kept at 15 cmH2O in both groups. After 6 h of mechanical ventilation, rats in both groups received RM to inflate reversible atelectasis of the lungs. Arterial blood gas analysis, lung computed tomography, histological evaluation, and comprehensive biochemical analysis were performed. RESULTS: OLA significantly improved lung aeration, arterial oxygenation, and gas exchange. Even after RM in both groups, the differences in these parameters between the two groups persisted, indicating that the atelectasis-induced respiratory dysfunction observed in the control group is not an easily reversible functional problem. Lung histological damage was severe in the dorsal dependent area in both groups, but was attenuated by OLA. White blood cell counts, protein concentrations, and tissue injury markers in the broncho-alveolar lavage fluid (BALF) were higher in the control than in the OLA group. Furthermore, levels of CXCL-7, a platelet-derived chemokine, were higher in the BALF from the control group, indicating that OLA protects the lungs by suppressing platelet activation. CONCLUSIONS: OLA shows protective effects against experimental ARDS, even when the ΔP is not decreased. In addition to reducing ΔP, maintaining lung aeration seems to be important for lung protection in ARDS.

DOI： 10.1186/s13054-018-2154-2

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Language：English   Publishing type：Research paper (scientific journal)  

PURPOSE: The aim of this study was to examine the relationship between FFP (fresh frozen plasma)/pRBC (packed red blood cell) transfusion ratio and outcomes in patients undergoing cardiovascular surgery. METHODS: This is a single center retrospective cohort study performed in a cardiovascular center. Patients undergoing cardiovascular surgery between January 2012 and October 2016 with or without massive transfusion (n = 1453). Patients' outcomes were compared based on FFP/pRBC transfusion ratio (FFP/pRBC > 1 or FFP/pRBC ≤ 1). RESULTS: In hospital mortality and rate of stroke and myocardial infarction was significantly higher in patients with less than 1 of FFP/pRBC transfusion ratio only in patients with massive transfusion (3.0 vs 8.8%, p = 0.001; 0.7 vs 6.4%, p < 0.001; 1.0 vs 3.2%, p = 0.047, respectively). CONCLUSIONS: Higher FFP/RBC ratio was associated with reduced risk of death, stroke and myocardial infarction only in patients with cardiovascular surgery receiving massive transfusion. Clinicians should be aware that judicious FFP replacement plays a critical role in the successful management of massive transfusion in cardiac surgery.

DOI： 10.1007/s00540-018-2508-6

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BACKGROUND: Fentanyl and remifentanil are widely used opioids in surgery, but it has not been evaluated whether the choice of opioids during surgery affects the patients' postoperative quality of recovery. Accordingly, we aim to compare postoperative recovery of fentanyl-based anesthesia with remifentanil-based anesthesia after laparoscopic surgery using the QoR 40 questionnaire (QoR-40). METHODS: The study was prospective, randomized, patient and investigator-blinded, controlled, clinical trial. Seventy patients undergoing laparoscopic or retroperitoneoscopic renal or ureteral surgery were recruited and randomized to either fentanyl or remifentanil based anesthesia groups. The primary outcome was the global QoR-40 at 24 h after surgery. RESULTS: The global median (interquartile range) QoR-40 score was 160 (138-177) in the fentanyl group (n = 32) and 140 (127-166) in the remifentanil group (n = 31). Physical comfort and physical independence, the two out of the five dimensions of the QoR-40, demonstrated significantly high scores in the fentanyl group (P = 0.047 and P = 0.032, respectively). CONCLUSION: Although the global QoR is higher in the fentanyl group by 20 points compared with remifentanil group, no significant differences revealed between the groups. Further studies with large numbers of subjects of the same gender are needed. TRIAL REGISTRATION: University Hospital Medical Information Network (UMIN),  UMIN000010464 . Registered 10 April 2013.

DOI： 10.1186/s12871-018-0547-z

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Kokuseido Publishing Co. Ltd  

A 32-year-old man underwent awake craniotomy for oligodendroglioma The patient received general anesthesia and had a laryngeal mask inserted to secure airway, and continuous infusion of propofol and remifentanil was started. After induction of anesthesia the patient developed seizure without obvious causes. To prevent seizure, phenytoin was administered. About seven hours after the induction of anesthesia infusion of propofol and remifentanil was discontinued to awake the patient The patient could not communicate adequately for thirty minutes from discontinuation of anesthetics, and developed complicated laryngospasm. Because of laryngospasm, we could not ventilate, and the patient's end tidal CO2 level increased to 60 mmHg. The patient's brain showed swelling rapidly and bleeding inside the tumor. Then we decided to convert to general anesthesia Although the tumor was excised partially, the patient did not show dysphasia after the operatioa The causes of insufficient emergence were thought to be prolonged infusion of propofol or administration of phenytoin, or effect of seizure. In such a case we should decide to convert to general anesthesia early, and prevent worsening the conditions.

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Language：Japanese   Publisher：克誠堂出版(株)  

症例は32歳男性で、3年前に全身性強直性痙攣を発症した。左前頭葉腫瘍を指摘され、開頭腫瘍摘出術と術後放射線化学療法を施行した。1年前に腫瘍の再発を認め、腫瘍が運動性言語野に及んでいたため、覚醒下開頭腫瘍摘出術を予定した。麻酔方法は、覚醒させるまで全身麻酔で管理する方針とし、ラリンジアルマスクで気道確保を行った。麻酔導入から約2時間後に手術を開始した。麻酔導入から約7時間後、プロポフォールとレミフェンタニルの投与を中止して覚醒を試みた。約15分後に体動が出現したが疎通は不可能で、覚醒を待つ間に喉頭痙攣を起こして換気不能に陥った。筋弛緩薬の投与で喉頭痙攣は解除されたが、換気が再開された時点で呼気終末二酸化炭素分圧は60mmHg程度まで上昇した。二酸化炭素の貯留とともに術野で急性脳腫脹をきたし、腫瘍内出血も認めた。麻酔薬投与中止から約45分後に覚醒を断念して全身麻酔へ移行した。手術は腫瘍部分摘出で終了したが、術後は明らかな失語や痙攣は見られず、術後13日目に大きな合併症なく退院した。

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2018&ichushi_jid=J01397&link_issn=&doc_id=20180710120012&doc_link_id=%2Fad3msuie%2F2018%2F006707%2F014%2F0748-0751%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fad3msuie%2F2018%2F006707%2F014%2F0748-0751%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Kokuseido Publishing Co. Ltd  

PECS block is a regional anesthesia for anterior chest wall. We present herein the case of 64-year-old woman who underwent partial mastectomy and axillary lymph node biopsy for left breast cancer complicated by interstitial pneumonia due to preoperative chemotherapy. We performed PECS-II block avoiding general anesthesia to prevent acute exacerbation of interstitial pneumonia During the operatioa she was lightly sedated using dexmedetomidine. Additional local anesthesia (1% lidocaine 1 ml) was performed during axillary lymph node biopsy. No oxygen was necessary and no evident symptoms of acute exacerbation of the interstitial pneumonia was observed in the perioperative period. Avoidance of general anesthesia by PECS block might be beneficial for the patients with interstitial pneumonia.

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Language：Japanese   Publisher：克誠堂出版(株)  

症例は64歳女性で、左外上部乳がんの診断で約半年前から術前化学療法を受け、乳房部分切除術および腋窩リンパ節生検を予定された。間質性肺炎再燃のリスクを考慮し、全身麻酔を避けpectoral nerve blockブロックのみで麻酔管理する方針とした。ブロックは仰臥位で、リニアプローブと22G Tuohy針を用いて超音波ガイド下に第4肋骨上、大胸筋と前鋸筋の間に0.25%レボブピバカインを40ml投与し、さらに傍胸骨で大胸筋全面に0.25%レボブピバカインを15ml投与した。術中は腋窩の最も背側の部分で疼痛を認め、1%リドカイン1mlの局所浸潤麻酔を要したが、その他は問題なく手術は予定どおり終了した。予術終了後の経過観察で、間質性肺炎の増悪を疑う症状および検査所見は認めなかった。

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2018&ichushi_jid=J01397&link_issn=&doc_id=20180608080010&doc_link_id=%2Fad3msuie%2F2018%2F006706%2F011%2F0611-0613%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fad3msuie%2F2018%2F006706%2F011%2F0611-0613%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer Tokyo  

Purpose: Hyperglycemia is a common issue in infants after cardiac surgery for congenital heart disease. Poor glycemic control is suspected to be associated with adverse postoperative outcomes. This study was performed to investigate clinical factors contributing to hyperglycemia in the perioperative period in infats. Methods: A total of 69 infants (aged 1–12 months) who were admitted to Yokohama City University Hospital Intensive Care Unit (ICU) after surgical repair of congenital heart diseases with cardiopulmonary bypass (CPB) were retrospectively analysed. Hyperglycemia was defined as blood glucose ≥ 250 mg/dL on ICU admission. Clinical background, operative factors, and postoperative factors were compared between the hyperglycemic and non-hyperglycemic groups. Additionally, multivariate analysis was performed to identify factors contributing to hyperglycemia. Results: Nineteen (27.5%) and 50 (72.5%) infants were classified into the hyperglycemic and non-hyperglycemic groups, respectively. Hyperglycemic infants were significantly younger, shorter, and weighed less, with a higher rate of chromosomal abnormalities. Intraoperatively, they also experienced longer CPB and surgery times and had higher peak lactate levels and higher inotropic requirements. Hyperglycemia was related to longer mechanical ventilation and longer ICU stays. Multivariate analysis detected intraoperative hyperglycemia, longer CPB time, younger age and chromosomal abnormality as significant factors. Conclusion: Adding to hyperglycemia during the operation, longer CPB time younger age and chromosomal abnormality were identified as predictors of high blood glucose levels at ICU admission.

DOI： 10.1007/s00540-017-2444-x

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Language：English   Publisher：FEDERATION AMER SOC EXP BIOL  

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Cellular bioenergetic failure caused by mitochondrial dysfunction is a key process of alveolar epithelial injury during acute respiratory distress syndrome (ARDS). Prolyl hydroxylases (PHDs) act as cellular oxygen sensors, and their inhibition activates hypoxia-inducible factor (HIF), resulting in enhanced cellular glycolytic activity, which could compensate for impaired mitochondrial function and protect alveolar epithelial cells from ARDS. Here, we evaluated the effects of pharmacological PHD inhibition with dimethyloxalylglycine (DMOG) on alveolar epithelial cell injury using in vitro and in vivo ARDS models. We established an in vitro model of alveolar epithelial injury mimicking ARDS by adding isolated neutrophils and LPS to cultured MLE12 alveolar epithelial cells. DMOG treatment protected MLE12 cells from neutrophil-LPS-induced ATP decline and cell death. Knockdown of HIF-1α or inhibition of glycolysis abolished the protective effect of DMOG, suggesting that it was exerted by HIF-1-dependent enhancement of glycolysis. Additionally, intratracheal DMOG administration to mice protected the alveolar epithelial barrier and improved arterial oxygenation, preventing ATP decline during LPS-induced lung injury. In summary, enhancement of glycolysis by PHD inhibition is a potential therapeutic approach for ARDS, protecting alveolar epithelial cells from bioenergetic failure and cell death.- Tojo, K., Tamada, N., Nagamine, Y., Yazawa, T., Ota, S., Goto, T. Enhancement of glycolysis by inhibition of oxygen-sensing prolyl hydroxylases protects alveolar epithelial cells from acute lung injury. FASEB J. 32, 2258-2268 (2018). www.fasebj.org.

DOI： 10.1096/fj.201700888R

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：English   Publishing type：Part of collection (book)   Publisher：Wolters Kluwer Health  

Laryngeal ultrasonography has mainly been performed after tracheal extubation. However, improvements in ultrasound technology now allow assessment of vocal cord function even under conditions of endotracheal intubation. We report herein the use of laryngeal ultrasonography in an endotracheally intubated patient after esophagectomy, which allowed us to make the presumptive diagnosis of bilateral recurrent nerve palsy before tracheal extubation. Qur experience suggests that laryngeal ultrasonography may be useful in assessing vocal cord function even in endotracheally intubated patients, although the indications and efficacy remain to be determined.

DOI： 10.1213/XAA.0000000000000601

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Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1096/fj.201700888R

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DOI： 10.1155/2018/9615264

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Magnesium has been investigated as an adjuvant for neuraxial anesthesia, but the effect of caudal magnesium on postoperative pain is inconsistent. The aim of this systematic review and meta-analysis was to evaluate the analgesic effect of caudal magnesium. METHODS: We searched six databases, including trial registration sites. Randomized clinical trials reporting the effect of caudal magnesium on postoperative pain after general anesthesia were eligible. The risk ratio for use of rescue analgesics after surgery was combined using a random-effects model. We also assessed adverse events. The I2 statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE. RESULTS: Four randomized controlled trials (247 patients) evaluated the need for rescue analgesics. In all four trials, 50 mg of magnesium was administered with caudal ropivacaine. The results suggested that the need for rescue analgesia was reduced significantly by caudal magnesium administration (risk ratio 0.45; 95% confidence interval 0.24-0.86). There was considerable heterogeneity as indicated by an I2 value of 62.5%. The Trial Sequential Analysis-adjusted confidence interval was 0.04-5.55, indicating that further trials are required. The quality of evidence was very low. The rate of adverse events was comparable between treatment groups. CONCLUSION: Caudal magnesium may reduce the need for rescue analgesia after surgery, but further randomized clinical trials with a low risk of bias and a low risk of random errors are necessary to assess the effect of caudal magnesium on postoperative pain and adverse events. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry UMIN000025344.

DOI： 10.1371/journal.pone.0190354

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Impact Journals LLC  

Objective: Aspiration of subglottic secretion is a widely used intervention to prevent ventilator-associated pneumonia (VAP). This study aimed to compare the efficacy of continuous and intermittent subglottic secretion drainage (SSD) in preventing VAP. Methods: A single-center randomized controlled trial was conducted on adult postoperative patients who were expected to undergo mechanical ventilation for more than 48 hours. Primary outcome measure was incidence of VAP and secondary outcome measures were length of mechanical ventilation and intensive-care unit (ICU) stay. Results: Fifty-nine patients received continuous SSD, while 60 patients received intermittent SSD. Of these 119 patients, 88 (74%) were excluded and 15 and 16 patients were allocated to receive continuous and intermittent SSD, respectively. VAP was detected in 4 (26.7%) and 7 (43.8%) patients in the continuous and intermittent groups, respectively, (p=0.320). The length of mechanical ventilation was significantly shorter (p=0.034) in the continuous group (99.5±47.1 h) than in the intermittent group (159.9±94.5 h). The length of ICU stay was also shorter (p=0.0097) in the continuous group (6.3±2.1 days) than the intermittent group (9.8±4.8 days). Conclusions: Although continuous SSD did not reduce the incidence of VAP, it reduced the length of mechanical ventilation and ICU stay when compared to intermittent SSD.

DOI： 10.18632/oncotarget.24630

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BACKGROUND: Emergence agitation (EA) is a frequent phenomenon in children recovering from general anaesthesia and increases the risk of self-injury. Previously, our group reported that stimulating the heart 7 (HT7) acupuncture point bilaterally using two neuromuscular transmission monitoring devices (NTMs) decreased the incidence of EA. However, bilateral stimulation is a barrier to clinical use because two NTMs are needed for one patient. OBJECTIVE: The objective of this study was to examine the efficacy of unilateral electrical stimulation of HT7 using an NTM to prevent EA in children. DESIGN: Prospective, double-blinded, randomized clinical trial. SETTING: Kanagawa Children's Medical Centre, Yokohama, Japan. PATIENTS: One hundred children (ages 18-96 months) with ASA-PS I or II, who were scheduled to undergo inguinal hernia repair or orchiopexy under sevoflurane anaesthesia. INTERVENTION: Patients were randomly assigned to one of the following two groups: (1) HT7 group: unilateral (right side) stimulation of the HT7 acupuncture point using a single-twitch electrical stimulus (1 Hz, 50 mA) throughout the surgery, and (2) control group: electrodes alone were attached to the HT7 point on the right side; an electrical stimulus was not applied. MAIN OUTCOME MEASURES: The primary outcome was the incidence of EA evaluated using the pediatric anaesthesia emergence delirium (PAED) scale. The secondary outcomes were the incidence of EA evaluated using Aono's scale, the severity of EA, PACU stay duration, and postoperative pain. RESULTS: There was no statistical difference between the incidence of EA in the HT7 and the control group (28.0% and 24.0%, respectively; P > 0.99). The risk ratio was 1.17 (95% confidence interval: 0.60-2.27). CONCLUSIONS: We observed that there was no effect of unilateral single-twitch electrical stimulation to the HT7 on the incidence of EA, contrary to the findings with bilateral HT7 stimulation.

DOI： 10.1371/journal.pone.0204533

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Language：English   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

BACKGROUND: Caudal anesthesia has been used for postoperative pain control in pediatric surgical patients, but the duration of the analgesic effect is occasionally unsatisfactory. Intravenous steroids have been shown to be effective for postsurgical pain management after certain surgeries. The aim of this meta-analysis with trial sequential analysis (TSA) was to evaluate the analgesic effect of steroids in patients administered with caudal anesthesia.
METHODS: This study was a systematic review and meta-analysis. A search of published literature was conducted in the MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases and in trial registration sites. Randomized controlled trials that compared intravenous steroids with a placebo in pediatric patients who had received caudal anesthesia for surgery were included in the study. The primary outcomes from the present metaanalysis were the analgesic duration and the number of patients who required rescue analgesics. The analgesic duration and incidence of rescue use were summarized using mean difference or risk ratio with a 97.5% confidence interval (CI), respectively. If the 97.5% CI of the mean difference or risk ratio included a value of 0 or 1, respectively, we considered the difference not to be significant. We used the random effects model to combine the results. Heterogeneity was quantified with the I-2 statistic. The quality of the trials was evaluated using the Cochrane methodology. Moreover, a TSA with a risk of type 1 error of 2.5% and power of 90% was performed. We established the minimum clinically meaningful difference of analgesic duration as 3 hours. The target sample size for meta-analysis was also calculated in the TSA. We also assessed adverse events.
RESULTS: Six trials with 424 patients were included; 211 patients received intravenous steroids. All trials compared dexamethasone of at least 0.5 mg/kg dose with a placebo. Dexamethasone prolonged the duration of caudal analgesia (mean difference, 244 minutes; 97.5% CI, 188-300). Heterogeneity was considerable with an I-2 value of 94.8%. Quality of evidence was very low. The TSA suggested that only 17.0% of the target sample size had been reached, but the cumulative Z score crossed the trial sequential monitoring boundary to indicate a benefit. Rescue use was reported in 4 studies with 260 patients. Rescue use was not significantly reduced in the dexamethasone group (risk ratio, 0.53; 97.5% CI, 0.09-3.30; I-2, 98.7%). No increase in adverse events was reported.
CONCLUSIONS: Intravenous dexamethasone prolongs the analgesic duration of caudal anesthesia. Trials to investigate the effectiveness of a lower dose of the dexamethasone in prolonging analgesic effects would be of interest. Further trials with a low risk of bias are necessary.

DOI： 10.1213/ANE.0000000000002453

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INTRODUCTION: Unintentional catecholamine flush caused by inappropriate release of an intravenous occlusion during use of a syringe pump in the intensive care unit (ICU) can have dangerous consequences in patients receiving critical care. We investigated whether anesthesiology residents understood how to deal with syringe pump occlusion in a simulated ICU setting. METHODS: We set up a mannequin that virtually simulated a sedated patient under mechanical ventilation after cardiac surgery, with epinephrine and dopamine being infused by syringe pumps to maintain blood pressure at 100/50 mm Hg. Prior to a participant entering the simulated ICU, one of the stopcocks for the catecholamine was occluded. Thereafter, the blood pressure of the mannequin dropped to 60/30 mm Hg. If the participant inappropriately released the occlusion, resulting in a catecholamine flush, an operator immediately elevated the blood pressure to 200/100 mm Hg. In the subsequent debriefing session, the simulation facilitator evaluated whether the participant could diagnose that intravenous occlusion was the cause of hypotension in this scenario. RESULTS: Sixteen anesthesiology residents participated in the study. Only 3 of 10 participants who had previous knowledge of how such situations should be handled could appropriately release back pressure. Eleven residents released the occlusion without relieving syringe pressure. After their debriefing sessions, all the participants were of the opinion that the present simulation training was impressive and useful for them. CONCLUSIONS: Anesthesiology residents might inappropriately handle a situation of intravenous occlusion in their clinical practice. It may be necessary for the manufacturers to improve the safety features of syringe pumps.

DOI： 10.1097/PTS.0000000000000232

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Language：English   Publisher：WILEY  

We conducted both conventional pairwise and Bayesian network meta-analyses to compare the clinical properties of supraglottic airway devices in children. We searched six databases for randomised clinical trials. Our primary end-points were oropharyngeal leak pressure, risk of insertion failure at first attempt, and blood staining risk. The risk of device failure, defined as the abandonment of the supraglottic airway device and replacement with a tracheal tube or another device, was also analysed. Sixty-five randomised clinical trials with 5823 participants were identified, involving 16 types of supraglottic airway device. Network meta-analysis showed that the i-gel, Cobra perilaryngeal airway and Proseal laryngeal mask airway (LMA((R))-Proseal) showed statistically significant differences in oropharyngeal leak pressure compared with the LMA((R))-Classic, with mean differences (95% credible interval, CrI) of 3.6 (1.9-5.8), 4.6 (1.7-7.6) and 3.4 (2.0-4.8) cmH(2)O, respectively. The i-gel was the only device that significantly reduced the risk of blood staining of the device compared with the LMA-Classic, with an odds ratio (95%CrI) of 0.46 (0.22-0.90). The risk (95%CI) of device failure with the LMA-Classic, LMA((R))-Unique and LMA-Proseal was 0.36% (0.14-0.92%), 0.49% (0.13-1.8%) and 0.50% (0.23-1.1%), respectively, whereas the risk (95%CI) of the i-gel and PRO-Breathe was higher, at 3.4% (2.5-4.7%) and 6.0% (2.8-12.5%), respectively. The risk, expressed as odds ratio (95%CrI), of insertion failure at first attempt, was higher in patients weighing &lt; 10 kg at 5.1 (1.6-20.1). We conclude that the LMA-Proseal may be the best supraglottic airway device for children as it has a high oropharyngeal leak pressure and a low risk of insertion. Although the i-gel has a high oropharyngeal leak pressure and low risk of blood staining of the device, the risk of device failure should be evaluated before its routine use can be recommended.

DOI： 10.1111/anae.13970

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Background
Postoperative nausea and vomiting is a distressing complication of surgery, and 5-HT3 receptor antagonists are often prescribed to prevent it. Ondansetron is the agent typically administered to prevent postoperative nausea and vomiting. Although ramosetron has a longer duration of action than ondansetron, it remains unclear whether ramosetron is the more effective medication. We performed an updated meta-analysis on the comparative efficacy of ramosetron and ondansetron in preventing postoperative nausea and vomiting.
Methods
We searched six databases for all trials that randomly assigned patients to ramosetron or ondansetron groups. The primary outcome was postoperative nausea or vomiting in the early, late, and next-day periods. The secondary outcomes were side effects of the medications. We used the random-effects model to combine the results. Trial sequential analyses were performed to correct for repetitive testing in the updated meta-analysis.
Results
Twenty-seven randomized controlled trials with 3,811 patients were included in the meta-analysis. The combined results of ramosetron vs. ondansetron efficacy in preventing postoperative nausea and vomiting were as follows: Risk ratio [95% confidence interval] = 0.82 [0.69-0.98] for early postoperative nausea, 0.76 [0.65-0.89] for late postoperative nausea, 0.69 [0.57-0.84] for next-day postoperative nausea, 0.78 [0.63-0.98] for early postoperative vomiting, 0.57 [0.45-0.72] for late postoperative vomiting, and 0.61 [0.43-0.86] for next-day postoperative vomiting. Dizziness was significantly lower in ramosetron groups than in ondansetron groups (risk ratio [95% confidence interval] = 0.81 [0.66-0.98]). Trial sequential analysis revealed that the results for late postoperative nausea, late postoperative vomiting, and next-day postoperative nausea were conclusive.
Conclusions
Ramosetron is more effective in preventing late postoperative nausea, late postoperative vomiting, and next-day postoperative nausea than ondansetron. The incidence of dizziness may be lower in patients receiving ramosetron than in patients receiving ondansetron.

DOI： 10.1371/journal.pone.0186006

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We present the management of a 15-year-old girl with acute myeloid leukemia who presented with massive hyperleukocytosis and neurological deficit due to intracerebral hemorrhage. Surgical intervention was considered but ultimately not undertaken because of the presence of massive hyperleukocytosis, thrombocytopenia, hypokalemia, and considerable discrepancy between the oxygen saturation values determined mechanically and by peripheral oximetry. Aggressive treatment of the hyperleukocytosis was immediately started, which improved the patient's overall condition and rendered surgical intervention unnecessary. This report shows that immediate treatment of massive hyperleukocytosis and critical interpretation of laboratory results in patients with hyperleukocytosis are warranted.

DOI： 10.1213/XAA.0000000000000553

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

BACKGROUND: Emergence agitation (EA) is a common complication in children after general anesthesia. The goal of this 2-phase study was (1) to develop a predictive model (EA risk scale) for the incidence of EA in children receiving sevoflurane anesthesia by performing a retrospective analysis of data from our previous study (phase 1) and (2) to determine the validity of the EA risk scale in a prospective observational cohort study (phase 2).
METHODS: Using data collected from 120 patients in our previous study, logistic regression analysis was used to predict the incidence of EA in phase 1. The optimal combination of the predictors was determined by a stepwise selection procedure using Akaike information criterion. The beta-coefficient for the selected predictors was calculated, and scores for predictors determined. The predictive ability of the EA risk scale was assessed by a receiver operating characteristic (ROC) curve, and the area under the ROC curve (c-index) was calculated with a 95% confidence interval (CI). In phase 2, the validity of the EA risk scale was confirmed using another data set of 100 patients (who underwent minor surgery under general anesthesia). The ROC curve, the c-index, the best cutoff point, and the sensitivity and specificity at the point were calculated. In addition, we calculated the gray zone, which ranges between the two points where sensitivity and specificity, respectively, become 90%.
RESULTS: In phase 1, the final model of the multivariable logistic regression analysis included the following 4 predictors: age (logarithm odds ratios [OR], -0.38; 95% CI, -0.81 to 0.00), Pediatric Anesthesia Behavior score (logarithm OR, 0.65; 95% CI, -0.09 to 1.40), anesthesia time (logarithm OR, 0.60; 95% CI, -0.18 to 1.19), and operative procedure (logarithm OR, 2.53; 95% CI, 1.30-3.75 for strabismus surgery and logarithm OR, 2.71; 95% CI, 0.99-4.45 for tonsillectomy). The EA risk scale included these 4 predictors and ranged from 1 to 23 points. In phase 2, the incidence of EA was 39%. The c-index of phase 1 was 0.84 (95% CI, 0.74-0.94), and the c-index of phase 2 was 0.81 (95% CI, 0.72-0.89). The best cutoff point for the EA risk scale was 11 (sensitivity = 87% and specificity = 61%). The gray zone ranged from 10 to 13 points, and included 38% of patients.
CONCLUSIONS: We developed and validated an EA risk scale for children receiving sevoflurane anesthesia. In our validation cohort, this scale has excellent predictive performance (c-index &gt; 0.8). The EA risk scale could be used to predict EA in children and adopt a preventive strategy for those at high risk. This score-based preventive approach should be studied prospectively to assess the safety and efficacy of such a strategy.

DOI： 10.1213/ANE.0000000000002126

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Language：Japanese   Publisher：真興交易(株)医書出版部  

症例は47歳女性で、高度肥満(BMI 68)に伴う労作制限、労作時低酸素血症、睡眠呼吸障害を呈したため、減量および二次性肥満の精査目的で入院した。入院1ヵ月前の室内気における動脈血液ガス分析でII型呼吸不全の所見を認め、肥満低換気症候群と診断した。入院初日の夜間就眠中に呼吸性アシドーシスの所見を認め、CO2ナルコーシスと診断した。患者は気道確保困難が予想されることと人工呼吸管理による合併症のハイリスクであることを考慮し、まずは非侵襲的陽圧換気を行う方針とした。SpO2 87〜95%程度を目標に、FIO2を0.25〜0.4の範囲で調整し、終始自発呼吸を温存した呼吸管理を継続した。呼吸モード変更後、約3時間で動脈血液ガス分析(ABG)所見が改善し、理学所見も改善傾向を認めた。以後は終日非侵襲的陽圧換気(NPPV)を継続し、安定した呼吸状態を維持した。

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Pulmonary emphysema impairs quality of life and increases mortality. It has previously been shown that administration of adenovirus vector expressing murine keratinocyte growth factor (KGF) before elastase instillation prevents pulmonary emphysema in mice. We therefore hypothesized that therapeutic administration of KGF would restore damage to lungs caused by elastase instillation and thus improve pulmonary function in an animal model. KGF expressing adenovirus vector, which prevented bleomycin-induced pulmonary fibrosis in a previous study, was constructed. Adenovirus vector (1.0x10(9) plaque-forming units) was administered intratracheally one week after administration of elastase into mouse lungs. One week after administration of KGF-vector, exercise tolerance testing and blood gas analysis were performed, after which the lungs were removed under deep anesthesia. KGF-positive pneumocytes were more numerous, surfactant protein secretion in the airspace greater and mean linear intercept of lungs shorter in animals that had received KGF than in control animals. Unexpectedly, however, arterial blood oxygenation was worse in the KGF group and maximum running speed, an indicator of exercise capacity, had not improved after KGF in mice with elastase-induced emphysema, indicating that KGF-expressing adenovirus vector impaired pulmonary function in these mice. Notably, vector lacking KGF-expression unit did not induce such impairment, implying that the KGF expression unit itself may cause the damage to alveolar cells. Possible involvement of the CAG promoter used for KGF expression in impairing pulmonary function is discussed.

DOI： 10.1111/1348-0421.12492

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Language：English   Publishing type：Part of collection (book)   Publisher：Springer Japan  

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) worsen quality of life in postoperative patients and, moreover, impose huge cost on hospitals. Previous clinical reports revealed that POD appears to be a risk for high mortality in the elderly and POCD appears to have long-lasting adverse effect on learning performance in children. Nevertheless nobody has proposed the effective way to cure them. We are still struggling in exploring mechanisms underlying POD and POCD because of the following reasons: (1) clinical definitions may be obscure, (2) underlying mechanisms are multifactorial, (3) less animal models comparable with patients are available. Under these difficulties, a considerable number of studies have contributed to identify key molecules and neural circuits essential for the establishment of these diseases and fortunately some of them appear to postulate reliable mechanisms. Integrating latest findings, here we discuss about these mechanisms underlying POD and POCD.

DOI： 10.1007/978-4-431-55624-4_9

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

Study objective: The glass vial of acetaminophen as an intravenous preparation (Acelio((R)), Terumo, Japan) has a strong internal negative pressure. The aim of our study was to determine if this negative pressure could result in medication administration errors if not released prior to connecting to the IV set.
Design: Questionnaire survey and simulation study.
Setting: University hospital and its affiliated hospitals.
Subjects: Fifty-two anesthesiologists in 6 different hospitals in Yokohama.
Measurements: A questionnaire on current practice was sent to the subjects. The authors then first calculated the internal pressure of the Acelio vial followed by a simulation set-up. This set-up measured the amount of saline that could be aspirated from a syringe loaded on a syringe pump connected via a secondary IV line when the Acelio vial was attached to the primary line without prior release of the internal pressure. The volume of aspiration was tested with two syringe sizes and with a fully open IV clamp vs partially closed.
Main results: Twenty-nine (56.9%) of 51 anesthesiologists who responded to the survey had connected the Acelio vial at least once without releasing the internal negative pressure, and 21 experienced consequences such as backflow of the venous blood. The pressure inside the Acelio vial was 81.8 +/- 19.6 Torr. With the clamp of the simulated IV line fully open, the amount of saline aspirated before the alarm of the syringe pump went off was 1.5 +/- 0.1 ml and 32 +/- 0.3 ml when 20 ml and 50 ml syringes were used, respectively. When the clamp was partially closed to allow 2 drops per second, this value was 1.3 +/- 0.1 ml and 2.3 +/- 0.1 ml, respectively. After removing the plunger from the holder of the syringe pump, an additional 7 ml (clamp partially closed) or 15-18 ml (clamp fully open) was aspirated in the subsequent 1 min.
Conclusions: A considerable number of anesthesiologists experienced consequences caused by the negative pressure inside the Acelio vial. This can also cause aspiration of the contents of the syringe pump. (C) 2016 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.jclinane.2016.12.002

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Background
The efficacy of devices for difficult intubation in paediatric patients, especially with a Cormack-Lehane grade 4 view, has yet to be established. We compared intubating parameters among three devices (the Airtraq (R), McGrath (R), and Macintosh laryngoscopes).
Methods
This study is a randomised cross-over trial. Participants were 20 anaesthetists. Each device was tested three times using a paediatric manikin with a Cormack-Lehane grade 4 view. The order to use each device was randomised by a computer-generated random sequence. The primary endpoint was the rate of successful intubation. Secondary endpoints included the time taken to intubate, percentage of glottic opening score, and severity of potential dental trauma.
Results
The successful intubation rates of the Airtraq (R), McGrath (R), and Macintosh laryngoscopes were 100%, 72%, and 45%, respectively. The risk ratio of the success rates of Airtraq (R) compared with McGrath (R) and Macintosh laryngoscopes were 1.40 (95% CI; 1.19-1.64, P &lt; 0.001) and 2.22 (95% CI; 1.68-2.94, P &lt; 0.001), respectively. The modified Cormack-Lehane grade and percentage of the glottic opening score were better for the Airtraq (R) than for the other devices. The dental trauma score was lower for the Airtraq (R) than for the other devices. There were no significant differences in the intubation time among the groups.
Conclusions
The Airtraq (R) had higher success rate, had better visibility, and was associated with less dental trauma than the other devices in a difficult paediatric intubation model with a Cormack-Lehane grade 4 view.

DOI： 10.1371/journal.pone.0171889

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：DAEDALUS ENTERPRISES INC  

BACKGROUND: Capnometry detects hypoventilation earlier than pulse oximetry while supplemental oxygen is being administered. We compared the end-tidal CO2 (P-ETCO2) measured using a newly developed oxygen nasal cannula with a CO2-sampling port and the P-aCO2 in extubated subjects after abdominal surgery. We also investigated whether the difference between P-aCO2 and P-ETCO2 is affected by resting, by spontaneous breathing with the mouth consciously closed, and by deep breathing with the mouth closed. METHODS: Adult post-abdominal surgery subjects admitted to the ICU were enrolled. After extubation, oxygen was supplied at 4 L/min using a capnometry-type oxygen cannula. The breathing frequency, P-ETCO2, and P-aCO2 were measured after 30 min of oxygen supplementation. P-ETCO2 was continuously measured during rest, during breathing with the mouth consciously closed, and during deep breathing with the mouth closed. The difference between P-ETCO2 and P-aCO2 during various breathing patterns was analyzed using the Bland-Altman method. RESULTS: Twenty subjects were included. The bias +/- SD (limits of agreement) for breathing frequency measured by capnometry compared with those obtained by direct measurement was 0.4 +/- 3.6 (-6.7 to 7.4). In P-ETCO2 compared with P-aCO2, the biases (limits of agreement) were 14.8 +/- 8.2 (-1.3 to 30.9) at rest, 10.2 +/- 6.4 (-2.3 to 22.7) with the mouth closed, and 7.7 +/- 5.6 (-3.2 to 18.6) for deep breathing with the mouth closed. P-ETCO2 determined using the capnometry device yielded unreliable and widely ranging values under various breathing patterns. However, deep breathing with the mouth closed decreased the difference between P-ETCO2 and P-aCO2, as compared with other breathing patterns. CONCLUSIONS: P-ETCO2 measurements under deep breathing with mouth closed with a capnometry-type oxygen cannula improved the prediction of the absolute value of P-aCO2 in extubated post-abdominal surgical subjects without respiratory dysfunction.

DOI： 10.4187/respcare.04634

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Introduction:Muscle wasting (MW) in catabolic conditions (e.g., burn injury [BI]) is a major risk factor affecting prognosis. Activation of interleukin-1 (IL-1)/nuclear factor-kappa B (NF-B), interleukin-6 (IL-6)/signal transducer and activator of transcription 3 (STAT3), and/or forkhead box O transcriptional factor (FOXO)-mediated gene transcription pathways is the pivotal trigger of inflammatory response-induced protein catabolic processes in muscle. The 7 acetylcholine receptors (7AChRs) are upregulated in macrophages and peripheral tissues including skeletal muscle during MW conditions. Stimulation of 7AChRs mitigates inflammatory responses. Hypothesis tested is that attenuation of inflammation by 7AChR stimulation with specific 7AChR agonist, GTS-21, will reverse BI-induced body mass and MW by modulating inflammatory and proteolytic signals.Methods:Body surface area (30%) BI or sham BI mice were treated with GTS-21 or saline. Tibialis anterior (TA) muscle was harvested at 6h, day 1 or 3 to examine inflammatory and proteolytic signals.Results:GTS-21 significantly ameliorated the BI-induced increased expression of inflammatory cytokines IL-6, IL-1, C-X-C motif chemokine ligand 2 (6h), phosphorylated STAT3, and NF-B (day 1) in TA muscle. GTS-21 also significantly inhibited BI-induced increase of MuRF1 and FOXO1 (day 1). Consistent with the cytokine and inflammatory mediator changes, BI-induced body weight and TA muscle mass loss at day 3 were mitigated by GTS-21 treatment. The beneficial effect of GTS-21 on BI changes was absent in methyllycaconitine (7AChR antagonist)-treated wild-type and 7AChR knockout mice.Conclusion:GTS-21 stimulation of 7AChRs, by modulating multiple molecular signals related to inflammation and proteolysis, attenuates protein wasting, evidenced by maintenance of body weight and attenuation of distant muscle mass loss after BI. GTS-21 can be a novel, potent therapeutic option for reversal of BI-induced MW.

DOI： 10.1097/SHK.0000000000000729

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：AMER THORACIC SOC  

Alveolar epithelial injury and increased alveolar permeability are hallmarks of acute respiratory distress syndrome. Apoptosis of lung epithelial cells via the Fas/Fas ligand (FasL) pathway plays a critical role in alveolar epithelial injury. Activation of hypoxiainducible factor (HIF)-1 by inhibition of prolyl hydroxylase domain proteins (PHDs) is a possible therapeutic approach to attenuate apoptosis and organ injury. Here, we investigated whether treatment with dimethyloxalylglycine (DMOG), an inhibitor of PHDs, could attenuate Fas/FasL-dependent apoptosis in lung epithelial cells and lung injury. DMOG increased HIF-1 alpha protein expression in vitro in MLE-12 cells, a murine alveolar epithelial cell line. Treatment of MLE-12 cells with DMOG significantly suppressed cell surface expression of Fas and attenuated FasL-induced caspase-3 activation and apoptotic cell death. Inhibition of the HIF-1 pathway by echinomycin or small interfering RNA transfection abolished these antiapoptotic effects of DMOG. Moreover, intraperitoneal injection of DMOG in mice increased HIF-1a expression and decreased Fas expression in lung tissues. DMOG treatment significantly attenuated caspase-3 activation, apoptotic cell death in lung tissue, and the increase in alveolar permeability in mice instilled intratracheally with FasL. In addition, inflammatory responses and histopathological changes were also significantly attenuated by DMOG treatment. In conclusion, inhibition of PHDs protects lung epithelial cells from Fas/FasL-dependent apoptosis through HIF-1 activation and attenuates lung injury in mice.

DOI： 10.1165/rcmb.2015-0266OC

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Gamma-aminobutyric acid (GABA) has been shown to induce excitation on immature neurons due to increased expression of Na+-K+-2Cl-co-transporter isoform 1 (NKCC1), and the transition of GABAergic signaling from excitatory to inhibitory occurs before birth in the rat spinal cord and spreads rostrally according to the developmental changes in cationchloride co-transporter expression. We previously showed that midazolam activates the hippocampal CA3 area and induces less sedation in neonatal rats compared with adolescent rats in an NKCC1-dependent manner. In the present study, we tested the hypothesis that propofol-induced loss of righting reflex (LORR) but not immobilizing actions are modulated by NKCC1-dependent mechanisms and reduced in neonatal rats compared with adolescent rats. We estimated neuronal activity in the cortex, hippocampus and thalamus after propofol administration with or without bumetanide, an NKCC1 inhibitor, by immunostaining of phosphorylated cyclic adenosine monophosphate-response element binding protein (pCREB). We studied effects of bumetanide on propofol-induced LORR and immobilizing actions in postnatal day 7 and 28 (P7 and P28) rats. The pCREB expression in the cortex (P = 0.001) and hippocampus (P = 0.01) was significantly greater in the rats receiving propofol only than in the rats receiving propofol plus bumetanide at P 7. Propofol-induced LORR or immobilizing effects did not differ significantly between P7 and P28. Bumetanide significantly enhanced propofol-induced LORR (P = 0.031) but not immobilization in P7 rats. These results are partially consistent with our hypothesis. They suggest that propofol may activate the rostral but not caudal central nervous system dependently on NKCC1, and these differential actions may underlie the different properties of sedative and immobilizing actions observed in neonatal rats.

DOI： 10.1371/journal.pone.0164125

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Tojo K, Goto T, Kurahashi K, European journal of anaesthesiology, 2016, vol. 33, no. 10, pp. 776-783, 2016

DOI： 10.1097/EJA.0000000000000460

DOI： 10.1097/eja.0000000000000460

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Other Link： http://orcid.org/0000-0002-1194-8636

Language：English   Publishing type：Research paper (scientific journal)   Publisher：PUBLIC LIBRARY SCIENCE  

Background
Quality of recovery (QoR) after surgery is a relevant outcome. The early postoperative quality of recovery of a patient can be determined using the QoR-40 questionnaire. The aim of this meta-analysis and Trial Sequential Analysis was to determine if perioperative administration of glucocorticosteroids improved patients' quality of recovery after general anesthesia and if adverse events occurred.
Methods
We searched six databases, including trial registration sites. Randomized clinical trials reporting the efficacy of glucocorticosteroids on quality of recovery evaluated using the QoR-40 after general anesthesia were eligible. The QoR-40 data were combined as the mean difference with confidence intervals using a random-effects model. The I-2 statistic was used to assess heterogeneity. The quality of the trials was evaluated using the Cochrane methodology. Moreover, Trial Sequential Analysis was carried out to prevent the inflation of type 1 errors caused by multiple testing and sparse data. We also assessed adverse events.
Results
Three randomized clinical trials (totaling 301 patients) were analyzed. The results from one published and four unpublished randomized clinical trialswere unavailable. Dexamethasone was investigated in all three trials, and the results suggested that it significantly improved QoR-40 at postoperative day one scores compared with placebo (mean difference [95% confidence interval]: 14.2 points [10.4 to 18.1]; P &lt; 0.001; I-2 = 0%). We could not conduct sensitivity analysis because of the absence of trials with low risk of bias. The Trial Sequential Analysis-adjusted confidence interval was -1.6 to 30.0, indicating that further trials are required. The reporting of adverse events was insufficient.
Conclusions
These findings indicate that perioperative dexamethasone administrationmay improve short-term(i.e., one day) quality of recovery after general anesthesia and surgery. We need more randomized clinical trials with low risk of bias assessing the effects of glucocorticosteroids on quality of life, other outcomes, and adverse events. Updated systematic reviews should then be conducted.

DOI： 10.1371/journal.pone.0162961

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BIOMED CENTRAL LTD  

Background: Compared to conventional tidal volume ventilation, low tidal-volume ventilation reduces mortality in cased of acute respiratory distress syndrome. The aim of the present study is to determine whether low tidal-volume ventilation reduces the production of inflammatory mediators in the lungs and improves physiological status during hepatic surgery.
Methods: We randomly assigned patients undergoing hepatectomy into 2 groups: conventional tidal-volume vs. low tidal-volume ( 12 vs. 6 mL.kg(-1) ideal body weight) ventilation with a positive end-expiratory pressure of 3 cm H2O. Arterial blood and airway epithelial lining fluid were sampled immediately after intubation and every 3 h thereafter.
Results: Twenty-five patients were analyzed. No significant changes were found in hemodynamics or acid-base status during the study. Interleukin-8 was significantly elevated in epithelial lining fluid from the low tidal-volume group. Oxygenation evaluated immediately after admission to the post-surgical care unit was significantly worse in the low tidal-volume group.
Conclusions: Low tidal-volume ventilation with low positive end-expiratory pressure may lead to pulmonary inflammation during major surgery such as hepatectomy.

DOI： 10.1186/s12871-016-0209-y

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

BACKGROUND Emergence agitation is common in children recovering from general anaesthesia. The prevention of emergence agitation remains an important challenge in the field of paediatric anaesthesia.
OBJECTIVE We aimed to examine the effectiveness of electrically stimulating the heart 7 (HT7) acupuncture site with a peripheral nerve stimulator (PNS) during surgery, for preventing emergence agitation in paediatric patients recovering from general anaesthesia.
DESIGN A double-blind, randomised, controlled, parallel-group trial.
SETTING Kanagawa Children's Medical Centre, Yokohama, Japan.
PATIENTS One hundred and twenty patients aged 18 to 96 months (American Society of Anesthesiologists physical status I or II) undergoing minor elective surgery under general anaesthesia with sevoflurane.
INTERVENTION Patients were randomly assigned to either undergo bilateral stimulation of HT7 with two PNS devices (1 Hz, 50 mA) during surgery (Group HT7) or a control group that did not undergo electrical stimulation of HT7 during surgery.
MAIN OUTCOME MEASURES The primary outcome was the incidence of emergence agitation evaluated in the postanaesthesia care unit (PACU) using the Paediatric Anaesthesia Emergence Delirium scale. The secondary outcomes were the time from operation completion to tracheal extubation, PACU stay duration and postoperative pain scores.
RESULTS The incidence of emergence agitation was significantly lower in the HT7 group compared with the control group (31.7 vs. 56.7%, respectively; P = 0.010). The risk ratio was 0.56 (95% confidence interval 0.36 to 0.86) and the number needed to treat was 4 (95% confidence interval 3 to 13). There were no statistically significant differences between groups in time from operation completion to tracheal extubation, PACU stay duration or postoperative pain.
CONCLUSION Bilateral electrical stimulation of HT7 using two PNS devices significantly decreases the incidence of emergence agitation.

DOI： 10.1097/EJA.0000000000000379

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Background
Hypertension often occurs after tracheal intubation using a Macintosh laryngoscope and may lead to rare but serious complications. The Macintosh laryngoscope may increase the incidence of hypertension because it requires forced alignment of the oral and pharyngeal axes in order to view the glottis. In contrast, the McGRATH MAC video laryngoscope does not require this manipulation. The objective of this study was to evaluate the incidence of hypertension after tracheal intubation using a McGRATH laryngoscope compared with a Macintosh laryngoscope.
Methods
Data of 360 consecutive patients who underwent general anesthesia with tracheal intubation by Macintosh laryngoscope or McGRATH video laryngoscope were obtained retrospectively. A total of 16 variables including patient characteristics, anesthetic drug used, and intubation techniques were extracted as potential factors affecting the incidence of hypertension after intubation. The incidence of hypertension after tracheal intubation was defined as an increase in systolic blood pressure (SBP) &gt; 20% of values immediately before intubation. Propensity scoring with inverse probability weighting was used to calculate the odds ratio for the incidence of hypertension after intubation with a McGRATH video laryngoscope as the primary outcome. The mean difference in SBP change between the two laryngoscopes was also calculated.
Results
A McGRATH laryngoscope was used in 68 of 360 patients (18%). The numbers of patients who increase in systolic blood pressure of more than 20% was 189 patients (53%). The odds ratio for the use of a McGRATH laryngoscope was 0.43 (95% confidence interval (CI), 0.19-0.96; P = 0.04). The mean difference in SBP change between the two laryngoscopes was -8.6 mmHg ( 95% CI, -17.4 to 0.2; P = 0.06).
Conclusions
The use of a McGRATH laryngoscope may reduce the incidence of hypertension after tracheal intubation compared to the Macintosh laryngoscope.

DOI： 10.1371/journal.pone.0155566

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Language：English   Publisher：FEDERATION AMER SOC EXP BIOL  

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Language：Japanese   Publishing type：Research paper (scientific journal)   Publisher：Kokuseido Publishing Co. Ltd  

Background: Pectoral nerve block (PECS block) is first reported by Blanco et al, and mainly used for analgesia for breast surgery in Japan. However, the spread of PECS block is unclear. Methods: Ultrasound guided PECS I and II blocks were performed in a cadaver, and the cadaver was dissected for evaluation of the spread of coloring matter. Results: The coloring matter by PECS I block was spread to the axillary region between the major and minor pectoral muscles, while PECS II block remained over the fascia of the serratus muscle from mid-clavicular line to middle axillary line. Two possible routes to the axillary region by PECS I include: dorsal to the pectoral minor muscle through the clavipectoral fascia, and over the pectoral minor muscle to me axillary sheath. Conclusions: Our cadaveric evaluation suggests that PECS I block produces more analgesia of the axillary region man PECS II. Further evaluation is needed in more cadavers.

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Mitochondrial disease has been uncommon conditions, still results in death during childhood in many cases. The ideal anesthetic pharmacological management strategy for adult patients with mitochondrial disease is currently unclear. In this study, we presented features of the anesthesia methods employed and the perioperative complications of patients in our institution and in previously published case reports. We report the use of general anesthesia 7 times in 6 adult patients with mitochondrial disease during 2004-2014. All cases were performed with maintained intravenous anesthesia. One case was reintubated on the day after surgery, but the cause of death was not directly related to anesthesia. One hundred and eleven general anesthesia cases in 97 adult patients with mitochondrial disease were described in 83 the literature. Although several severe perioperative complications and deaths have been reported, malignant hyperthermia had not been reported in adult cases, and metabolic disorder called propofol infusion syndrome had also not been reported in adult patients undergone total intravenous anesthesia. Perioperative complications of lactic acidosis were reported more in inhalation anesthesia than intravenous anesthesia. Therefore we recommended intravenous anesthesia rather than inhalation anesthesia for adult mitochondrial disease. (C) 2015 Elsevier B.V. and Mitochondria Research Society. All rights reserved.

DOI： 10.1016/j.mito.2015.11.004

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The aim of this study was to reveal the effect of anesthesiologist's mental workload during induction of general anesthesia. Twenty-two participants were categorized into anesthesiology residents (RA group, n = 13) and board certified anesthesiologists (CA group, n = 9). Subjects participated in three simulated scenarios (scenario A: baseline, scenario B: simple addition tasks, and scenario C: combination of simple addition tasks and treatment of unexpected arrhythmia). We used simple two-digit integer additions every 5 seconds as a secondary task. Four kinds of key actions were also evaluated in each scenario. In scenario C, the correct answer rate was significantly higher in the CA versus the RA group (RA: 0.370 +/- 0.050 versus CA: 0.736 +/- 0.051, P &lt; 0.01, 95% CI -0.518 to -0.215) as was the score of key actions (RA: 2.7 +/- 1.3 versus CA: 4.0 +/- 0.00, P = 0.005). In a serious clinical situation, anesthesiologists might not be able to adequately perform both the primary and secondary tasks. This tendency is more apparent in young anesthesiologists.

DOI： 10.1155/2016/1058750

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Ota S, Yazawa T, Tojo K, Baba Y, Uchiyama M, Goto T, Kurahashi K, Journal of intensive care, 2016, vol. 4, pp. 8, 2016

DOI： 10.1186/s40560-016-0130-y

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Other Link： http://orcid.org/0000-0002-1194-8636

Language：English   Publisher：AMER THORACIC SOC  

DOI： 10.1165/rcmb.2015-0266OC

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BACKGROUND: Patients with acute respiratory distress syndrome receiving mechanical ventilation show inhomogeneous lung aeration. Atelectasis during uneven mechanical ventilation leads to alveolar hypoxia and could therefore result in lung inflammation and injury. We aimed to elucidate whether and how atelectasis causes alveolar hypoxia-induced inflammation during uneven mechanical ventilation in an open-chest differential-ventilation rat model. METHODS: We first investigated inflammatory and histological changes in the bilateral lungs of unilaterally ventilated rats, in which the right lung was atelectatic and the left lung was ventilated with high tidal volume (HTV). In the next series, we investigated the effects of normal tidal volume (NTV) ventilation of the right lungs with 60 % O2 or 100 % N2 during HTV ventilation of the left lungs. Then, proinflammatory cytokine secretions were quantified from murine lung epithelial (MLE15) and murine alveolar macrophage (MH-S) cells cultured under a hypoxic condition (5 % O2) mimicking atelectasis. Further, activities of nuclear factor (NF)-κB and hypoxia-inducible factor (HIF)-1 were assessed in the nonventilated atelectatic lung and MLE15 cells cultured under the hypoxic condition. Finally, effects of NF-κB inhibition and HIF-1α knockdown on the cytokine secretions from MLE15 cells cultured under the hypoxic condition were assessed. RESULTS: The nonventilated atelectatic lungs showed inflammatory responses and minimal histological changes comparable to those of the HTV-ventilated lungs. NTV ventilation with 60 % O2 attenuated the increase in chemokine (C-X-C motif) ligand (CXCL)-1 secretion and neutrophil accumulation observed in the atelectatic lungs, but that with 100 % N2 did not. MLE15 cells cultured with tumor necrosis factor (TNF)-α under the hypoxic condition showed increased CXCL-1 secretion. NF-κB and HIF-1α were activated in the nonventilated atelectatic lungs and MLE15 cells cultured under the hypoxic condition. NF-κB inhibition abolished the hypoxia-induced increase in CXCL-1 secretion from MLE15 cells, while HIF-1α knockdown augmented it. CONCLUSIONS: Atelectasis causes alveolar hypoxia-induced inflammatory responses including NF-κB-dependent CXCL-1 secretion from lung epithelial cells. HIF-1 activation in lung epithelial cells is an anti-inflammatory response to alveolar hypoxia in atelectatic lungs.

DOI： 10.1186/s40635-015-0056-z

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DOI： 10.1097/EJA.0000000000000323

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Background
Numerous studies have demonstrated the beneficial effects of preoperative administration of oral carbohydrate (CHO) or oral rehydration solution (ORS). However, the effects of preoperative CHO or ORS on postoperative quality of recovery after anesthesia remain unclear. Consequently, the purpose of the current study was to evaluate the effect of preoperative CHO or ORS on patient recovery, using the Quality of Recovery 40 questionnaire (QoR-40).
Methods
This prospective, randomized, controlled clinical trial included American Society of Anesthesiologists (ASA) physical status 1 and 2 adult patients, who were scheduled to undergo a surgical procedure of body surface. Subjects were randomized to one of the three groups: 1) preoperative CHO group, 2) preoperative ORS group, and 3) control group. The primary outcome was the global QoR-40 administered 24 h after surgery. Intraoperative use of vasopressor, intraoperative body temperature changes, and postoperative nausea and vomiting (PONV) were also evaluated.
Results
We studied 134 subjects. The median [interquartile range (IQR)] global QoR-40 scores 24 h after the surgery were 187 [177-197], 186 [171-200], and 184 [171-198] for the CHO, ORS, and control groups, respectively (p = 0.916). No significant differences existed between the groups regarding intraoperative vasopressor use during the surgery (p = 0.475).
Conclusions
Results of the current study indicated that the preoperative administration of either CHO or ORS did not improve the quality of recovery in patients undergoing minimally invasive body surface surgery.

DOI： 10.1371/journal.pone.0133309

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Background: The descending antinociceptive system (DAS) is thought to play crucial roles in the antinociceptive effect of spinal cord stimulation (SCS), especially through its serotonergic pathway. The nucleus raphe magnus (NRM) in the rostral ventromedial medulla is a major source of serotonin [5-hydroxytryptamine (5-HT)] to the DAS, but the role of the dorsal raphe nucleus (DRN) in the ventral periaqueductal gray matter is still unclear. Moreover, the influence of the noradrenergic pathway is largely unknown. In this study, we evaluated the involvement of these serotonergic and noradrenergic pathways in SCS-induced antinociception by behavioral analysis of spinal nerve-ligated (SNL) rats. We also investigated immunohistochemical changes in the DRN and locus coeruleus (LC), regarded as the adrenergic center of the DAS, and expression changes of synthetic enzymes of 5-HT [tryptophan hydroxylase (TPH)] and norepinephrine [dopamine beta-hydroxylase (D beta H)] in the spinal dorsal horn.
Results: Intrathecally administered methysergide, a 5-HT1-and 5-HT2-receptor antagonist, and idazoxan, an alpha(2)-adrenergic receptor antagonist, equally abolished the antinociceptive effect of SCS. The numbers of TPH-positive serotonergic and phosphorylated cyclic AMP response element binding protein (pCREB)-positive neurons and percentage of pCREB-positive serotonergic neurons in the DRN significantly increased after 3-h SCS. Further, the ipsilateral-to-contralateral immunoreactivity ratio of D beta H increased in the LC of SNL rats and reached the level seen in naive rats, even though the number of pCREB-positive neurons in the LC was unchanged by SNL and SCS. Moreover, 3-h SCS did not increase the expression levels of TPH and D beta H in the spinal dorsal horn.
Conclusions: The serotonergic and noradrenergic pathways of the DAS are involved in the antinociceptive effect of SCS, but activation of the DRN might primarily be responsible for this effect, and the LC may have a smaller contribution. SCS does not potentiate the synthetic enzymes of 5HT and norepinephrine in the neuropathic spinal cord.

DOI： 10.1186/s12990-015-0039-9

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Cognitive function can be affected by the estrous cycle. However, the effect of the estrous cycle on synaptic functions is poorly understood. Here we show that in female rats, inhibitory-avoidance (IA) task (hippocampus-dependent contextual fear-learning task) drives GluA2-lacking Ca2+-permeable AMPA receptors (CP-AMPARs) into the hippocampal CA3-CA1 synapses during all periods of the estrous cycle except the proestrous period, when estrogen levels are high. In addition, IA task failed to drive CP-AMPARs into the CA3-CA1 synapses of ovariectomized rats only when estrogen was present. Thus, changes in the stoichiometry of AMPA receptors during learning depend on estrogen levels. Furthermore, the induction of long-term potentiation (LTP) after IA task was prevented during the proestrous period, while intact LTP is still expressed after IA task during other period of the estrous cycle. Consistent with this finding, rats conditioned by IA training failed to acquire hippocampus-dependent Y-maze task during the proestrous period. On the other hand, during other estrous period, rats were able to learn Y-maze task after IA conditioning. These results suggest that high estrogen levels prevent the IA learning-induced delivery of CP-AMPARs into hippocampal CA3-CA1 synapses and limit synaptic plasticity after IA task, thus preventing the acquisition of additional learning.

DOI： 10.1371/journal.pone.0131359

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DOI： 10.4187/respcare.03557

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DOI： 10.1016/j.jss.2014.11.011

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Isoflurane was previously the major clinical anesthetic agent but is now mainly used for veterinary anesthesia. Studies have reported widespread sites of action of isoflurane, suggesting a wide array of side effects besides sedation. In the present study, we phenotyped isoflurane-treated mice to investigate the postanesthetic behavioral effects of isoflurane. We applied comprehensive behavioral test batteries comprising sensory test battery, motor test battery, anxiety test battery, depression test battery, sociability test battery, attention test battery, and learning test battery, which were started 7 days after anesthesia with 1.8% isoflurane. In addition to the control group, we included a yoked control group that was exposed to the same stress of handling as the isoflurane-treated animals before being anesthetized. Our comprehensive behavioral test batteries revealed impaired latent inhibition in the isoflurane-treated group, but the concentration of residual isoflurane in the brain was presumably negligible. The yoked control group and isoflurane-treated group exhibited higher anxiety in the elevated plus-maze test and impaired learning function in the cued fear conditioning test. No influences were observed in sensory functions, motor functions, antidepressant behaviors, and social behaviors. A number of papers have reported an effect of isoflurane on animal behaviors, but no systematic investigation has been performed. To the best of our knowledge, this study is the first to systematically investigate the general health, neurological reflexes, sensory functions, motor functions, and higher behavioral functions of mice exposed to isoflurane as adults. Our results suggest that the postanesthetic effect of isoflurane causes attention deficit in mice. Therefore, isoflurane must be used with great care in the clinical setting and veterinary anesthesia.

DOI： 10.1371/journal.pone.0122118

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DOI： 10.1177/1357633X14562735

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DOI： 10.1053/j.jvca.2014.06.022

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER JAPAN KK  

Ventral disc protrusions have been neglected because they are asymptomatic. Lumbar sympathetic nerve block (LSNB) is one of the clinical choices for refractory low back pain treatment. Leakage of the contrast medium may occur and lead to complications, especially when using a neurolytic agent. In this study, we retrospectively reviewed the magnetic resonance images (MRIs) of 52 consecutive patients with refractory low back pain due to lumbar spinal canal stenosis who underwent LSNB, and graded ventral disc protrusion at the L1/2 to L5/S1 vertebral discs on a three-point scale (grade 0 = no protrusion, grade 1 = protrusion without migration, grade 2 = protrusion with migration). We also determined if there was leakage of contrast medium in LSNB. Ventral disc protrusion was observed in all patients, and 75 % (39/52) had grade 2 protrusion in the L1/2-L3/4 vertebral discs. Moreover, the incidence of contrast medium leakage was significantly higher at the vertebrae that had grade 2 protrusion than at those with less protrusion. We revealed a higher incidence of ventral disc protrusion of the lumbar vertebrae than previously reported, and that the incidence of leakage in LSNB increased when ventral disc protrusion was present. To avoid complications, attention should be paid to ventral disc protrusions before performing LSNB.

DOI： 10.1007/s00540-014-1871-1

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© 2015 The Author. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. OBJECTIVES Acute kidney injury is common following cardiac surgery. Experimental models of acute kidney injury suggest that successful therapy should be implemented within 24-48 h of renal injury. However, it is difficult to detect acute kidney injury shortly after cardiac surgery, because creatinine concentration is diluted by cardiopulmonary bypass. We hypothesized that, following cardiopulmonary bypass, creatinine reduction ratios would correlate with haematocrit reduction ratios and would be associated with the incidence of acute kidney injury. METHODS We collected demographic and blood test data from consecutive patients (n = 1137) who had undergone cardiac surgery with cardiopulmonary bypass. The creatinine reduction ratio was calculated as follows: (preoperative creatinine-postoperative creatinine)/preoperative creatinine. Patients were assigned to either of two groups. The first group (Group 1) was used to determine the threshold for acute kidney injury, and the second group (Group 2) was used to assess diagnostic performance. Acute kidney injury was defined as an increase in serum creatinine level &gt;0.3 mg/dl or &gt;150% from baseline. RESULTS The incidence of acute kidney injury was 14.5% (79/545) in Group 1 and 15.5% (92/592) in Group 2. Postoperatively, creatinine concentration correlated strongly with haematocrit concentration (Pearson&#039;s r2: 0.91). In Group 1, the area under the receiver operating characteristic curve, sensitivity and specificity were 0.71, 64.1 and 66.4%, respectively, for creatinine reduction ratios of &lt;20%. In Group 2, the odds ratio, positive predictive value, negative predictive value and relative risk for creatinine reduction ratio performance were 4.3 (95% confidence interval 2.6-7.0), 0.27 (0.21-0.32), 0.92 (0.89-0.95) and 3.42 (2.22-5.27), respectively. CONCLUSIONS The creatinine reduction ratio may be associated with perioperative renal injury. Therefore, it is a good diagnostic indicator with high performance, and may be useful in detecting acute kidney injury at an earlier stage relative to conventional means. In addition, using creatinine reduction ratios in this manner is financially feasible.

DOI： 10.1093/icvts/ivv184

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A "cannot-ventilate, cannot-intubate" situation is critical. In difficult airway management, transtracheal jet ventilation (TTJV) has been recommended as an invasive procedure, but specialized equipment is required. However, the influence of upper airway resistance (UAR) during TTJV has not been clarified. The aim of this study was to compare TTJV using a manual jet ventilator (MJV) and the oxygen flush device of the anestheticmachine (AM). We made a model lung offering variable UAR by adjustment of tracheal tube size that can ventilate through a 14-G cannula. We measured side flow due to the Venturi effect during TTJV, inspired tidal volume (TVi), and expiratory time under various inspiratory times. No Venturi effect was detected during TTJV with either device. With the MJV, TVi tended to increase in proportion to UAR. With AM, significant variations in TVi was not detected with changes in any UAR. In conclusion, UAR influenced forward flow of TTJV in the model lung. The influence of choked flow from the Venturi effect was minimal under all UAR settings with the MJV, but the AM could not deliver sufficient flow.

DOI： 10.1155/2015/454807

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Language：English   Publisher：WILEY-BLACKWELL  

The purpose of this meta-analysis was to determine the efficacy of lidocaine in preventing laryngospasm during general anaesthesia in children. An electronic search of six databases was conducted. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were adhered to. We included randomised controlled trials reporting the effects of intravenous and/or topical lidocaine on the incidence of laryngospasm during general anaesthesia. Nine studies including 787 patients were analysed. The combined results demonstrated that lidocaine is effective in preventing laryngospasm (risk ratio (RR) 0.39, 95% CI 0.24-0.66; I-2=0). Subgroup analysis revealed that both intravenous lidocaine (RR 0.34, 95% CI 0.14-0.82) and topical lidocaine (RR 0.42, 95% CI 0.22-0.80) lidocaine are effective in preventing laryngospasm. The results were not affected by studies with a high risk of bias. We conclude that, both topical and intravenous lidocaine are effective for preventing laryngospasm in children.

DOI： 10.1111/anae.12788

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：OXFORD UNIV PRESS  

Children with complex congenital heart diseases often require repeated cardiac catheterization; however, children are more radiosensitive than adults. Therefore, radiation-induced carcinogenesis is an important consideration for children who undergo those procedures. We measured entrance skin doses (ESDs) using radio-photoluminescence dosimeter (RPLD) chips during cardiac catheterization for 15 pediatric patients (median age, 1.92 years; males, n = 9; females, n = 6) with cardiac diseases. Four RPLD chips were placed on the patient's posterior and right side of the chest. Correlations between maximum ESD and dose-area products (DAP), total number of frames, total fluoroscopic time, number of cine runs, cumulative dose at the interventional reference point (IRP), body weight, chest thickness, and height were analyzed. The maximum ESD was 80 ± 59 (mean ± standard deviation) mGy. Maximum ESD closely correlated with both DAP (r = 0.78) and cumulative dose at the IRP (r = 0.82). Maximum ESD for coiling and ballooning tended to be higher than that for ablation, balloon atrial septostomy, and diagnostic procedures. In conclusion, we directly measured ESD using RPLD chips and found that maximum ESD could be estimated in real-time using angiographic parameters, such as DAP and cumulative dose at the IRP. Children requiring repeated catheterizations would be exposed to high radiation levels throughout their lives, although treatment influences radiation dose. Therefore, the radiation dose associated with individual cardiac catheterizations should be analyzed, and the effects of radiation throughout the lives of such patients should be followed.

DOI： 10.1093/jrr/rru050

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：AMER PHYSIOLOGICAL SOC  

Pulmonary hypertension (PH) is associated with significant morbidity and mortality. Vasoactive intestinal peptide (VIP) and pituitary adenylyl cyclase activating peptide (PACAP) have pulmonary vasodilatory and positive inotropic effects via receptors VPAC1 and VPAC2, which possess a similar affinity for both peptides, and PAC1, a PACAP-preferring receptor. VIP is a promising option for PH treatment; however, various physiological effects of VIP have limited its clinical use. We investigated the effects of VPAC1 and VPAC2 selective agonists VIP and PACAP to explore more appropriate means of treatment for PH. We examined hemodynamic changes in right ventricular systolic pressure (RVSP), systemic blood pressure (SBP), total pulmonary resistance index (TPRI), total systemic resistance index, and cardiac index (CI) in response to their agonists with monocrotaline (MCT)-induced PH and explored involvement of VIP/PACAP expression and receptors in PH. Sprague-Dawley rats were divided into the MCT group (administered MCT 60 mg/kg) and control group. In MCT-induced PH, decreased VIP and PACAP were associated with upregulation of VPAC1, VPAC2, and PAC1 in lung tissues. Intravenous injection of VPAC2-selective agonist BAY 55-9837 and VIP, but not [Ala(11,22,28)] VIP, improved the CI. The decrease in SBP with VPAC2 agonist was significantly less than that in the control. Although they decreased SBP, these agonists hardly affected RVSP in the control. Activation of VPAC2 receptor with BAY 55-9837 effectively improved RVSP, TPRI, and CI in MCT-induced PH, suggesting a VPAC2 agonist as a possible promising treatment for PH.

DOI： 10.1152/japplphysiol.00861.2013

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Language：English   Publishing type：Research paper (other academic)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：English   Publishing type：Research paper (other academic)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

DOI： 10.1111/anae.12788

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER HEIDELBERG  

In isolated area in Japan, only one anesthesiologist must often do new anesthetic techniques such as ultrasound-guided procedures without receiving any teaching. One solution to this problem may involve teleanesthesia, by which experienced anesthesiologists teach novices in remote places, by utilizing information communicatioin technologies. FaceTime (TM) (Apple, USA), which provides 120p of the resolution and 30 frames per second (fps) is an application of free visual communications using iPod Touch (TM), iPhone (TM) or iPad (TM) (Apple, USA). We investigated the delay time, the loss of the frames and the picture quality of iPad (as the device in the teaching site) in combination with iPod Touch, iPhone4 or iPhone5 (as the device in the isolated site) during FaceTime. At the operating rooms in Sado General Hospital (SGH) located in Sado Island (population; approximately 60,000), Japan, an anesthesiologist prepared 3 mobile devices (iPod Touch, iPhone4 or iPhone5). He called the other anesthesiologist at Yokohama City University Hospital (YCUH; approximately 300 km apart) by FaceTime using 1 of 3 mobile devices. The anesthesiologist at YCUH received the FaceTime call using iPad. After the connection was established, the display of the same cervical ultrasound image at SGH was sent to YCUH to evaluate the distinctness visually. Then we measured the delay time of every second (n = 60) and the loss of the frames (total frames = 30 fps x 60 s = 1,800) in each device for a minute. P &lt; 0.01 was statistically significant. The quality of the pictures on the iPad display sent from iPhone5 was distinctly the best visually. The delay time of iPhone5 was significantly longer than the others (iPod Touch; 0.14 +/- A 0.02 s, iPhone4; 0.13 +/- A 0.02 s, iPhone5; 0.19 +/- A 0.03 s), but clinically acceptable. The loss of the frames of iPhone5 (20; 1.1 %) was significantly less than the others (iPhone4; 900, 50.0 %, iPod Touch; 902, 50.1 %). To teach anesthetic techniques in remote place by FaceTime, iPhone5 as the devise in isolate site was optimum compared with iPod Touch and iPhone4.

DOI： 10.1007/s10877-013-9514-x

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DOI： 10.1016/j.bbrc.2014.01.082

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Language：Japanese  

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Other Link： http://search.jamas.or.jp/link/ui/2014121636

Language：English   Publishing type：Research paper (scientific journal)   Publisher：Ovid Technologies (Wolters Kluwer Health)  

BACKGROUND: General anesthesia induces long-lasting cognitive and learning deficits. However, the underlying mechanism remains unknown. The GluA1 subunit of AMPAR is a key molecule for learning and synaptic plasticity, which requires trafficking of GluA1-containing AMPARs into the synapse. METHODS: Adult male rats were exposed to 1.8% isoflurane for 2 h and subjected to an inhibitory avoidance task, which is a hippocampus-dependent contextual fear learning paradigm (n = 16 to 39). The in vitro extracellular field potential of hippocampal synapses between the Schaffer collateral and the CA1 was evaluated using a multielectrode recorder (n = 6 per group). GluA1 expression in the synaptoneurosome was assessed using Western blotting (n = 5 to 8). The ubiquitination level of GluA1 was evaluated using immunoprecipitation and Western blotting (n = 7 per group). RESULTS: Seven days after exposure to 1.8% isoflurane for 2 h (Iso1.8), the inhibitory avoidance learning (control vs. Iso1.8; 294 ± 34 vs. 138 ± 28, the mean ± SEM [%]; P = 0.002) and long-term potentiation (125.7 ± 6.1 vs. 105.7 ± 3.3; P < 0.001) were impaired. Iso1.8 also temporarily increased GluA1 in the synaptoneurosomes (100 ± 9.7 vs. 138.9 ± 8.9; P = 0.012) and reduced the GluA1 ubiquitination, a main degradation pathway of GluA1 (100 ± 8.7 vs. 71.1 ± 6.1; P = 0.014). CONCLUSIONS: Isoflurane impairs hippocampal learning and modulates synaptic plasticity in the postanesthetic period. Increased GluA1 may reduce synaptic capacity for additional GluA1-containing AMPARs trafficking.

DOI： 10.1097/ALN.0000000000000269

DOI： 10.1097/aln.0000000000000269

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Reproductive success depends on a robust and appropriately timed preovulatory luteinizing hormone (LH) surge, which is induced by the activation of gonadotropin-releasing hormone (GnRH) neurons in response to positive feedback from increasing estrogen levels. Here we document an increase in postsynaptic GluR2-lacking Ca2+-permeable AMPA-type glutamate receptors (CP-AMPARs) at synapses on GnRH neurons on the day of proestrus in rats, coincident with the increase in estrogen levels. Functional blockade of CP-AMPARs depressed the synaptic responses only on the day of proestrus and concomitantly attenuated the LH surge. Thus, the phasic synaptic incorporation of postsynaptic CP-AMPARs on GnRH neurons is involved in the generation of the LH surge. © 2013 The Authors.

DOI： 10.1016/j.neuroscience.2013.06.040

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DOI： 10.1213/ANE.0b013e3182a07063

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Language：Japanese   Publisher：(公社)日本放射線技術学会  

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DOI： 10.1213/ANE.0b013e31829847a1

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BACKGROUND: Studies have compared sealing effects of the newly developed tapered endotracheal tube cuff with the conventional cylindrical cuff. In this study, we compared the difference between cuffs with regard to the increase in intracuff pressure during nitrous oxide (N(2)O) exposure. METHODS: Two types of cuffs were studied using a model trachea connected to a mechanical test lung: high-volume, low-pressure cuff (Mallinckrodt Hi-Lo(TM), Covidien, Dublin, Ireland) and tapered cuff (Mallinckrodt TaperGuardTM, Covidien). The intracuff pressure was set at 20 cm H(2)O, and the increase in pressure was measured during mechanical ventilation using 66% N(2)O. Intracuff pressures were recorded after 5, 10, 15, 30, 45, and 60 minutes of exposure to N(2)O. RESULTS: The intracuff pressure recorded during the first 15 minutes of N(2)O exposure in high-volume, low-pressure cuffs was significantly higher than tapered cuffs (2-way repeated-measures analysis of variance, P < 0.0001 for internal diameters [IDs] 7.0 and 7.5 mm, P = 0.0004 for ID 8.0 mm, P = 0.0013 for ID 8.5 mm), and there were also statistically significant differences regarding interaction of time and cuff type (P < 0.0001 for IDs 7.0, 7.5, 8.0, and 8.5 mm). The difference in mean cuff pressures among groups after 10 minutes of N(2)O exposure was -18.5 (SE, 1.4; 99% confidence interval, -22.8 to -14.2; P < 0.0001) for ID 7.5 mm. Tapered endotracheal tube cuffs sealed the trachea with fewer dimples on the carina side of the cuff. Dimples on the cuff surface probably increase the surface for N(2)O diffusion. Therefore, fewer dimples result in a smaller surface area through which N(2)O can diffuse. CONCLUSION: During general anesthesia with N(2)O, the intracuff pressure of tapered endotracheal tube cuffs did not increase as rapidly as it did in conventional high-volume, low-pressure cuffs. The pressure in both types of cuffs increased rapidly when exposed to 66% N(2)O, and hence continuous or frequent monitoring is recommended.

DOI： 10.1213/ANE.0b013e318279b399

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DOI： 10.3233/THC-130754

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DOI： 10.1016/j.neuroscience.2013.01.062

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Other Link： http://orcid.org/0000-0001-9790-9867

Language：English   Publishing type：Research paper (scientific journal)   Publisher：Ovid Technologies (Wolters Kluwer Health)  

BACKGROUND: It has been shown that γ-aminobutyric acid exerts excitatory actions on the immature brain due to the increased expression of Na(+)-K(+)-2Cl(-) cotransporter isoform 1. The authors sought to clarify whether midazolam, a γ-aminobutyric acid-mimetic hypnotic agent, causes neuronal excitation that can be blocked by bumetanide, a selective inhibitor of Na(+)-K(+)-2Cl(-) cotransporter isoform 1. Furthermore, the authors examined whether bumetanide potentiates the sedative effects of midazolam in neonatal rats. METHODS: The authors measured the effects of midazolam with or without bumetanide on the cytosolic Ca(2+) concentration ([Ca](2+)(i)) in hippocampal slices (n=3 in each condition) from rats at postnatal days 4, 7, and 28 (P4, P7, and P28) using fura-2 microfluorometry. Neuronal activity in the hippocampus and thalamus after intraperitoneal administration of midazolam with or without bumetanide was estimated by immunostaining of phosphorylated cyclic adenosine monophosphate-response element-binding protein (n=12 in each condition). Furthermore, the authors assessed effects of bumetanide on the sedative effect of midazolam by measuring righting reflex latency (n=6 in each condition). RESULTS: Midazolam significantly increased [Ca](2+)(i) in the CA3 area at P4 and P7 but not at P28. Bumetanide inhibited midazolam-induced increase in [Ca](2+)(i). Midazolam significantly up-regulated phosphorylated cyclic adenosine monophosphate-response element-binding protein expression in a bumetanide-sensitive manner in the hippocampus at P7 but not P28. Bumetanide enhanced the sedative effects of midazolam in P4 and P7 but not P28 rats. CONCLUSION: These results suggest that γ-aminobutyric acid A receptor-mediated excitation plays an important role in attenuated sedative effects of midazolam in immature rats.

DOI： 10.1097/ALN.0b013e31829e4b05

DOI： 10.1097/aln.0b013e31829e4b05

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Language：English   Publisher：AMER THORACIC SOC  

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BACKGROUND: Surgery with general anesthesia disturbs circadian rhythms, which may lead to postoperative sleep disorders and delirium in patients. However, it is unclear how circadian rhythms are affected by different anesthetics administered at different times during the rest-activity cycle. We hypothesized that pentobarbital (an agonist at the γ-aminobutyric acid A receptors) and ketamine (an antagonist at the N-methyl-d-aspartate receptors) would have differential effects on circadian rhythms, and these effects would also be influenced by the time of their administration (the active versus resting phase). METHODS: Rats were divided into 4 groups according to the anesthetic administered (pentobarbital or ketamine) and the timing of intraperitoneal administration (active/night phase or resting/day phase). Using online pineal microdialysis, we analyzed pineal melatonin secretion and locomotor activity rhythms in rats under a light/dark (12/12-hour) cycle for 5 days after anesthesia and microdialysis catheter implantation. The data were analyzed for rhythmicity by cosinor analysis. RESULTS: Ketamine administered during the resting phase produced 65- and 153-minute phase advances, respectively, in melatonin secretion and locomotor activity rhythms on the first day after anesthesia. In contrast, ketamine administered during the active phase produced 43- and 235-minute phase delays. Pentobarbital had no effect on the phase of either melatonin secretion or locomotor activity, irrespective of the timing of administration. When administered during the active phase, both anesthetics decreased the amplitude of melatonin secretion on the day after anesthesia; when administered during the resting phase, however, neither anesthetic affected the amplitude. The amplitude of locomotor activity decreased in all animals for 3 days after anesthesia. CONCLUSION: Ketamine has opposite phase-shifting effects on circadian rhythms according to the time of administration, whereas pentobarbital has no effect. Furthermore, both anesthetics decrease the postoperative amplitude of pineal melatonin secretion if administered during the active, but not the resting, phase of the 24-hour rest-activity cycle.

DOI： 10.1213/ANE.0b013e3182632bcb

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Throat packing is commonly placed in the pharynx before starting oral and maxillofacial surgery under general anesthesia to protect the airway from aspiration of blood and surgical debris. Complications such as airway obstruction may arise if any of the throat packing is retained after extubation, and less commonly, swallowing of the throat packing has been reported. We report endoscopic removal of throat packing gauze swallowed during general anesthesia.

DOI： 10.1097/SCS.0b013e3182564bb5

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：AMER SOC CLINICAL INVESTIGATION INC  

Stressful events during early childhood can have a profound lifelong influence on emotional and cognitive behaviors. However, the mechanisms by which stress affects neonatal brain circuit formation are poorly understood. Here, we show that neonatal social isolation disrupts molecular, cellular, and circuit developmental processes, leading to behavioral dysfunction. Neonatal isolation prevented long-term potentiation and experience-dependent synaptic trafficking of alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptors normally occurring during circuit formation in the rodent barrel cortex. This inhibition of AMPA receptor trafficking was mediated by an increase of the stress glucocorticoid hormone and was associated with reduced calcium/calmodulin-dependent protein kinase type II (CaMKII) signaling, resulting in attenuated whisker sensitivity at the cortex. These effects led to defects in whisker-dependent behavior in juvenile animals. These results indicate that neonatal social isolation alters neuronal plasticity mechanisms and perturbs the initial establishment of a normal cortical circuit, which potentially explains the long-lasting behavioral effects of neonatal stress.

DOI： 10.1172/JCI63060

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Language：English   Publisher：WILEY-BLACKWELL  

DOI： 10.1111/j.1365-2044.2012.07071_2.x

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE BV  

During early postnatal brain development, experience-driven delivery of AMPA receptors to synapses participates in the initial organization of conical function. By combining virus-mediated in vivo gene delivery with in vitro whole cell recordings, we identified a subunit-specific developmental program of experience-driven AMPA receptor delivery to synapses in rat barrel cortex. We expressed green fluorescent protein (GFP)-tagged AMPA receptors (GFP-GluR1, or GFP-GluR4) into layer 2/3 pyramidal neurons at two distinct developmental periods, postnatal day (P)8-P10 and P12-P14. Two days after viral infection, acute brain slices were prepared, and synaptic transmission from layer 4 to layer 2/3 was analyzed by whole cell recordings. We found that whisker experience drives GluR4 but not GluR1 into these synapses early in postnatal development (P8-1310). However, at P12-14, GluR1 but not GluR4 is delivered into synapses by whisker experience. This precise developmental plan suggests unique plasticity properties endowed in different AMPA receptor subunits which shape the initial experience-driven organization of cortical function. (C) 2011 Elsevier B.V. All rights reserved.

DOI： 10.1016/j.brainres.2011.11.033

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Language：Japanese   Publisher：(株)ジェフコーポレーション  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY-BLACKWELL  

We compared the effects of the Airway Scope (R) on haemodynamic responses during tracheal intubation with those of direct laryngoscopy in normotensive and hypertensive patients. The systolic blood pressure, diastolic blood pressures and heart rate were recorded: (a) before anaesthesia; (b) immediately before intubation; (c) at intubation; and (d) 1, 2, 3, 4 and 5 min after intubation. In normotensive patients, the increase in blood pressure and heart rate over time were significantly lower with the Airway Scope than with the Macintosh laryngoscope (p &lt; 0.003). In hypertensive patients, however, there was no difference in the changes over time in any of these haemodynamic measures between the two devices (p &gt; 0.05). We conclude that the Airway Scope attenuates haemodynamic responses to tracheal intubation in comparison with the laryngoscope in normotensive but not in hypertensive patients.

DOI： 10.1111/j.1365-2044.2011.06802.x

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：CHURCHILL LIVINGSTONE  

DOI： 10.1016/j.bjoms.2011.01.016

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Pulmonary fibrosis has high rates of mortality and morbidity, but there is no established therapy at present. We demonstrate here that bleomycin-induced pulmonary fibrosis in mice is ameliorated by intratracheal administration of keratinocyte growth factor (KGF)-expressing adenovirus vector. Progressive pulmonary fibrosis was created by continuous subcutaneous administration of 120 mg/kg of bleomycin subcutaneously using an osmotic pump twice from Day 1 to 7 and Day 29 to 35. The mice initially exhibited subpleural fibrosis and then exhibited advanced fibrosis in the parenchyma of the lungs. These histopathological changes were accompanied by reduced lung compliance (0.041 ± 0.011 versus 0.097 ± 0.004; P < 0.001), reduced messenger expression of surfactant proteins, and reduced KGF messenger expression in the lungs at 4 weeks compared with naive group. Intratracheal instillation of Ad-KGF at 1 week after the first administration of bleomycin increased KGF mRNA expression in the lungs compared with the fibrosis-induced mice that received saline alone. The phenotype was associated with alveolar epithelial cell proliferation, increased pulmonary compliance (0.062 ± 0.005 versus 0.041 ± 0.011; P = 0.023), and decreased mortality (survival rate on Day 56: 68.8% versus 0%; P = 0.002), compared with mice receiving only the saline vehicle. These observations suggest the therapeutic utility of a KGF-expressing adenoviral vector for pulmonary fibrosis.

DOI： 10.1165/rcmb.2010-0092OC

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Background: Direct laryngoscopy along with manual inline stabilization (MIS) is currently the standard care for patients with suspected neck injuries. However, cervical collar immobilization is more commonly performed in the prehospital environment, and its early removal is necessary before intubation. We hypothesized that if usability of Airway Scope (AWS) in a difficult airway could also bring merits to intubation under cervical collar immobilization, unnecessary risk caused by the removal of a neck collar may be prevented.
Methods: In this crossover study, 30 consenting patients presenting for surgery were assigned to undergo intubation using AWS. Neck was stabilized manually and by a neck collar in a random order before laryngoscopy was performed by the same anesthesiologist. Measurements include interincisor distance (IID), success rate, intubation time, and fluoroscopic examination of the upper and middle cervical spine.
Results: IID was notably narrower after application of a neck collar (mean +/- SE: MIS, 19 mm +/- 1 mm; collar, 10 mm +/- 1 mm; p &lt; 0.01). One and 9 failures were encountered in MIS and collar groups, respectively (p = 0.012). Intubation time proved no statistical significance. Extension of craniocervical junction was observed in both groups, but occipitoatlantal joint was significantly more extended in collar group (median [range]: AWS, 10-degree angle [-1 to 20-degree angle]; collar, 14-degree angle [5 to 26-degree angle]; p &lt; 0.01). Discussion: AWS laryngoscopy under cervical collar immobilization fails to meet our expectation. Intubation failed in 30% of the cases in collar group whereas only 3.3% of the cases in MIS group. Significant difference of mouth opening limitation is probably the major reason, as 7 of 9 failed cases in collar group had IID &lt;10 mm. This was insufficient to insert the 18-mm blade of AWS. In addition, occipitoatlantal joint suffered a greater extension when wearing a neck collar. Differences in the method to stabilize the neck may be the reason.
Conclusion: When compared with cervical collar immobilization, AWS laryngoscopy along with MIS seems to be a safer and more definite method to secure airway of neck-injured trauma patients because it limits less mouth opening and upper cervical spine movement.

DOI： 10.1097/TA.0b013e3181e75873

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Publisher：Elsevier {BV}  

DOI： 10.1016/j.brainres.2011.02.077

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY-BLACKWELL PUBLISHING, INC  

Background
The Pentax-AWS (AWS (R)), a new video laryngoscope, has been shown to be useful in cases of difficult intubation. We hypothesized that the AWS (R) would be more useful in the settings of a narrow upper airway than the Macintosh laryngoscope. We compared each device in simulated scenarios of representative difficulty of tracheal intubation using a manikin. The primary endpoint was the rate of successful intubation.
Methods
With each device, 23 anesthesiologists performed tracheal intubation in a SimMan (R) manikin in the following scenarios: (1) normal airway, (2) tongue edema, (3) cervical spine rigidity, (4) pharyngeal obstruction, (5) jaw trismus, (6) tongue edema with pharyngeal obstruction. The intubation time and success rate were measured. Each participant was asked to rate the difficulty of intubation (1=very easy; 5=very difficult).
Results
In the scenarios of tongue edema and tongue edema with pharyngeal obstruction, the AWS (R) yielded a higher success rate (100% vs. 34.8%; P &lt; 0.001, 65.2% vs. 21.7%; P=0.006), a shorter intubation time [14.6 (7.0) vs. 33.4 (13.0) s; P &lt; 0.001, 24.5 (12.0) vs. 37.6 (11.9); P=0.047; mean (standard deviation)], and a lower difficulty score [2 (1-4) vs. 5 (1-5); P &lt; 0.001, 4 (2-5) vs. 5 (3-5); P &lt; 0.001; median (range)], compared with the Macintosh laryngoscope.
Conclusion
The AWS (R) has an advantage over the Macintosh laryngoscope in simulated tongue edema and tongue edema with pharyngeal obstruction. Further studies in a clinical setting are necessary to confirm these findings.

DOI： 10.1111/j.1399-6576.2010.02363.x

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Language：English   Publisher：Elsevier {BV}  

DOI： 10.1016/j.neures.2010.09.006

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DOI： 10.1097/TA.0b013e3181c4529e

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：SPRINGER TOKYO  

The Airway Scope AWS-S100(A (R)) (AWS, Pentax, Tokyo), a rigid video laryngoscope with integrated tube guidance that has recently become commercially available, helped the authors to establish airways in two patients with in-hospital cardiopulmonary arrest, after failed attempts to intubate the patients using the Macintosh laryngoscope (that only commanded the Cormack-Lehane grade 4 glottic views), the laryngeal mask airway, and even surgical cricothyroidotomy for the second case. This showed the utility of the AWS in the management of difficult airway cases even in emergency settings.

DOI： 10.1007/s00540-010-0955-9

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY-BLACKWELL PUBLISHING, INC  

The fibreoptic assisted laryngoscope is a new airway device. We compared the fibreoptic assisted laryngoscope with the Bullard laryngoscope, Macintosh laryngoscope and fibreoptic bronchoscope in a manikin with a simulated Cormack and Lehane Grade 4 laryngoscopic view. Eighteen anaesthetists intubated the manikin&apos;s trachea using these devices and the success rate of intubation was measured. They were then asked to rate the subjective difficulty of intubation. The success rate (95% confidence interval) was 100% (94.6-100) with the fibreoptic assisted laryngoscope, 88.9% (80.5-97.3) using the Bullard laryngoscope, 37.0% (24.1-49.9) with the Macintosh laryngoscope, and 22.2% (11.1-33.3) using the fibreoptic bronchoscope. Tracheal intubation using the fibreoptic assisted laryngoscope or Bullard laryngoscope is easier than that using the Macintosh laryngoscope or fibreoptic bronchoscope by subjective difficulty score. All of the intubations were successful with the fibreoptic assisted laryngoscope without practice. These results suggest that fibreoptic assisted laryngoscope may be a useful tool for paediatric difficult intubation.

DOI： 10.1111/j.1365-2044.2008.05795.x

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Publisher：Ovid Technologies (Wolters Kluwer Health)  

DOI： 10.1097/ALN.0b013e31819daf15

DOI： 10.1097/aln.0b013e31819daf15

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE BV  

The authors previously demonstrated that isoflurane, a widely used volatile anesthetic, induced depolarization and increased the frequency of spontaneous action potentials in principal dopamine neurons in rat substantia nigra pars compacta. We studied the effects of isoflurane on voltage-dependent K channels to clarify the mechanisms of the increase in excitability in these neurons. Voltage-clamp whole-cell recordings were made in rat midbrain slices. We recorded the outward membrane currents in response to depolarizing voltage steps from -120 mV and -25 mV and isolated the transient outward current mediated through A-type K channels by subtraction. Isoflurane at clinically relevant concentrations accelerated the decay of the A-type K current and delayed the recovery from inactivation without changing the steady-state inactivation curves. Isoflurane did not affect the non-inactivating outward current. Addition of 4-aminopyridine partially occluded the excitatory effects of isoflurane in current-clamp recordings. These results demonstrate that isoflurane accelerated the inactivation and delayed the recovery from inactivation of A-type K channels in principal neurons in rat substantia nigra pars compacta without affecting delayed rectifier K channels. These effects may contribute in part to excitation of these neurons and the isoflurane-induced increases in dopamine release reported in vitro and in vivo. (C) 2007 Elsevier B.V. All rights reserved.

DOI： 10.1016/j.ejphar.2007.10.062

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Other Link： http://orcid.org/0000-0001-9790-9867

Publisher：Ovid Technologies (Wolters Kluwer Health)  

DOI： 10.1097/ALN.0b013e318178819b

DOI： 10.1097/aln.0b013e318178819b

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BLACKWELL PUBLISHING  

We compared the Airway Scope((R)) with a gum elastic bougie and fibreoptic bronchoscope in a manikin with a simulated Cormack and Lehane Grade 3 laryngoscopic view. Twenty-seven anaesthetists intubated the trachea of the manikin with these devices and the time required for intubation was measured. They were then asked to rate the subjective difficulty of intubation (1 = very easy; 5 = very difficult). Mean (SD) intubation times were 16.6 (11.2) s with the Airway Scope, 29.4 (10.9) s with the gum elastic bougie (p &lt; 0.0001), and 30.6 (20.0) s with the fibreoptic bronchoscope (p &lt; 0.0001). The median (range) difficulty was 2 (1-4) with the Airway Scope, 3 (2-4) with the gum elastic bougie (p &lt; 0.001), and 2 (1-5) with the fibreoptic bronchoscope (p = 0.014). In Cormack and Lehane grade 3 laryngoscopic views, the Airway Scope may enable faster and easier tracheal intubation than does a Macintosh laryngoscope with a gum elastic bougie or a fibreoptic bronchoscope.

DOI： 10.1111/j.1365-2044.2007.05152.x

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：AMER PHYSIOLOGICAL SOC  

Ischemia-reperfusion not only damages the affected organ but also leads to remote organ injuries. Hepatic inflow interruption usually occurs during hepatic surgery. To investigate the influence of liver ischemia-reperfusion on lung injury and to determine the contribution of tidal volume settings on liver ischemia-reperfusion-induced lung injury, we studied anesthetized and mechanically ventilated rats in which the hepatic inflow was transiently interrupted twice for 15 min. Two tidal volumes, 6 ml/kg as a low tidal volume (IR-LT) and 24 ml/kg as a high tidal volume (IR-HT), were assessed after liver ischemia-reperfusion, as well as after a sham operation, 6 ml/kg (NC-LT) and 24 ml/kg (NC-HT). Both the IR-HT and IR-LT groups had a gradual decline in the systemic blood pressure and a significant increase in plasma TNF-alpha concentrations. Of the four groups, only the IR-HT group developed lung injury, as assessed by an increase in the lung wet-to-dry weight ratio, the presence of significant histopathological changes, such as perivascular edema and intravascular leukocyte aggregation, and an increase in the bronchoalveolar lavage fluid TNF-alpha concentration. Furthermore, only in the IR-HT group was airway pressure increased significantly during the 6-h reperfusion period. These findings suggest that liver ischemia-reperfusion caused systemic inflammation and that lung injury is triggered when high tidal volume ventilation follows liver ischemia-reperfusion.

DOI： 10.1152/ajplung.00151.2006

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DOI： 10.1089/hum.2006.137

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Language：Japanese  

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Other Link： http://orcid.org/0000-0001-9790-9867

Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE BV  

ATP-sensitive K (K-ATP) channels, widely expressed in cytoplasmic membranes of neurons, couple cell metabolism to excitability. They are considered to play important roles in controlling seizure activity during hypoxia and in neuroprotection against cell damage during hypoxia, ischemia and excitotoxicity. It is known that adenosine augments the opening of cardiac surface K-ATP channels by reducing the sensitivity of these channels to ATP blockade. We investigated whether a similar modulation occurs in neuronal channels. Whole cell voltage-clamp recordings were made using rat midbrain slices to record the membrane current and conductance in principal neurons of the substantia nigra pars compacta (SNc). When the pipette solution contained 1 mM ATP, the membrane current at -60 mV and cellular conductance remained stable for at least 15 min. When slices were treated with (-)-N-6-2-phenylisopropyl adenosine (R-PIA), a selective agonist for A, adenosine receptors, in the same condition, the outward current developed slowly to the amplitude of 109.9 +/- 26.6 pA, and conductance increased to 229 +/- 50% of the baseline. These changes were strongly inhibited by 200 mu M tolbutamide, a K-ATP channel blocker, suggesting that opening of K-ATP channels mediated these changes. Pretreatment with 8-cyclopentyltheophylline (CPT), a selective A, adenosine receptor antagonist, abolished the outward current and conductance increases. Treatment of adenosine resulted in the similar changes sensitive to tolbutamide. These changes were abolished by CPT. These results suggest that activation of A, adenosine receptors promotes the opening of K-ATP channels in principal neurons of the SNc by removing the blockade by ATP. (c) 2006 Elsevier B.V. All rights reserved.

DOI： 10.1016/j.brainres.2006.09.085

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DOI： 10.1097/01.aco.0000192811.56161.23

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STUDY OBJECTIVE: The aim of this study is to test the hypothesis that the amount of nitrogen that accumulates within the closed breathing system would be greater during open abdominal surgery than during superficial surgery with small wounds. DESIGN: Prospective, comparative study. SETTING: Operating rooms of a university hospital. PATIENTS: Fourteen American Society of Anesthesiologists physical status I and II adult patients scheduled for abdominal surgery (n = 7) or tympanoplasty (n = 7). INTERVENTIONS: After induction of anesthesia and endotracheal intubation, the patients were denitrogenated for 30 minutes using 100% oxygen at a fresh gas flow of 10 L/min. The breathing system was then closed and patients were anesthetized using 60% xenon in oxygen, supplemented with epidural anesthesia in the abdominal surgery group and sevoflurane in the tympanoplasty group. MEASUREMENTS: Nitrogen concentration in the breathing system was determined by gas chromatography immediately before and 2 hours after the breathing system was closed. MAIN RESULTS: The median (range) increase in nitrogen concentration during the 2-hour period of closed circuit anesthesia was greater in the abdominal surgery patients than in the tympanoplasty patients (6.5% [4.0%-10.2%] vs 2.5% [1.4%-8.4%], P = 0.035, Mann-Whitney U test). CONCLUSIONS: The amount of nitrogen accumulation during closed circuit anesthesia is greater during open abdominal surgery than in superficial surgery such as tympanoplasty. We postulate that during open abdominal surgery, nitrogen in the ambient air enters the body across the peritoneum and then diffuses into the alveoli to be exhaled.

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Language：Japanese   Publisher：Japanese Society of Medical Instrumentation  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

DOI： 10.1097/00000542-200303000-00034

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DOI： 10.1097/00000542-200301000-00002

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Background: The minimum alveolar concentration (MAC) of xenon in the elderly has not been determined. Moreover, because xenon inhibits the activity of the N-methyl-D-aspartate receptors, and because N-Methyl-D-aspartate receptor antagonists such as ketamine and MK-801 exert sex-dependent actions, we hypothesized that the MAC of xenon would also be sex-dependent.
Methods: Forty-eight patients of both sexes (24 patients of each sex), who were aged 65 yr or older and were undergoing elective laparotomy, were anesthetized with inhalational induction of xenon. Those who demonstrated marked agitation received supplemental propofol intravenously. After tracheal intubation, the end-tidal concentration of xenon was maintained at 45 (women only), 50, 55, 60, 65, 70, or 75% (men only) for at least 15 min before skin incision. These concentrations were randomly allocated to four patients of each sex. Each patient was monitored for the presence or absence of any purposeful bodily movement for I min following skin incision. The MAC of xenon was calculated separately for men and women using logistic regression analysis.
Results: The MAC of xenon was 69.3% (95% Cl, 63.0-75.6%) for men and 51.1% (44.6-57.6%) for women. The two 95% confidence intervals did not overlap, indicating a statistically significant difference (P &lt; 0.05).
Conclusions: The MAC of xenon in the elderly is higher in men than in women.

DOI： 10.1097/00000542-200211000-00015

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STUDY OBJECTIVE: To investigate the quality of medical air in a hospital in the metropolitan area. DESIGN: Prospective study. SETTING: University hospital in the metropolitan Tokyo area. INTERVENTIONS: Medical air introduced into a bio-clean operating room was sampled. MEASUREMENTS: The concentrations of nitric monoxide (NO), nitrogen dioxide (NO(2)), sulfur dioxide (SO(2)), and carbon monoxide (CO) in the medical air were measured every 30 minutes for 15 days. MAIN RESULTS: The concentrations (mean +/- SD) of NO, NO(2), SO(2), and CO were 34.4 +/- 35.0 ppb (range 0-200 ppb), 7.7 +/- 5.5 ppb (0-29 ppb), 33.8 +/- 2.9 ppb (21-46 ppb), and 1.65 +/- 0.87 ppm (0.5-7.5 ppm), respectively. The concentrations of these gases peaked at rush hours within a day. CONCLUSIONS: In the metropolitan area, we occasionally provide our patients with medical air of poor quality.

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Language：English   Publisher：CANADIAN ANESTHESIOLOGISTS SOC  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Background: It has recently been demonstrated that the approximately 40-Hz spectral power of the midlatency auditory evoked potential (MLAEP) correlates well with wakefulness during desflurane or propofol anesthesia. The aim of this study was to characterize how other inhalational anesthetics affects the MLAEP as the patients regain responsiveness to simple verbal command during emergence from anesthesia.
Methods: Sixty patients were randomly assigned to receive xenon, isoflurane, sevoflurane, or nitrous oxide (N2O) supplemented with epidural anesthesia. During emergence, the concentration of an anesthetic was decreased in 0.1-minimum alveolar concentration (MAC) decrements from 0.8 MAC or from 70% in the case of N2O, and each new concentration was maintained for 15 min. Every 5 min during each equilibration period, the MLAEP was recorded and the patients were asked to open their eyes and squeeze and release the investigator's hand. This process was repeated until the first response to either of these commands was observed.
Results: Thirteen patients were excluded because of technical reasons. The preanesthetic MLAEP showed a periodic wave-form, where the Na-Pa-Nb complex was the most prominent component contributing to the high energy around 29-39 Hz in the power spectrum. Emergence from xenon, isoflurane, and sevoflurane anesthesia produced similar changes in the MLAEP. The spectral power for the frequency 29 Hz or greater was severely suppressed at 0.8 MAC but significantly recovered between the concentration only 0.1 MAC higher that permitting the first response to command and that associated with the first response. In contrast, N2O hardly affected the MLAEPs, even at the concentrations producing unresponsiveness. Two patients did not lose responsiveness even at the highest concentration tested (70%).
Conclusions: The MLAEP is closely associated with responsiveness to verbal command during emergence from anesthesia with xenon, isoflurane, and sevoflurane but not with N2O.

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Background: Although more than 30 yr ago the minimum alveolar concentration (MAC) of xenon was determined to be 71%, that previous study had technological limitations, and no other studies have confirmed the MAC value of xenon since. The current study was designed to confirm the MAC value of xenon in adult surgical patients using more modern techniques.
Methods: Sixty patients were anesthetized with sevoflurane with or without xenon. They were randomly allocated to one of four groups; patients in group 1 received no xenon, whereas those in groups 2, 3, and 4 received end-tidal concentrations of 20, 40, and 60%, respectively (n = 15 each group). Target end-tidal sevoflurane concentrations were chosen using the "up-and-down" method in each group. After steady state sevoflurane and xenon concentrations were maintained for at least 15 min, each patient was monitored for a somatic response at surgical incision. Somatic response was defined as any purposeful bodily movement. The MAC of sevoflurane and its reduction by xenon was evaluated using the multiple independent variable logistic regression model.
Results: The interaction coefficient of the multiple variable logistic regression was not significantly different from zero (P = 0.143). The MAC of xenon calculated as xenon concentration that would reduce MBC of sevoflurane to 0% was 63.1%.
Conclusions: The authors could not determine whether interaction in blocking somatic responses in 50% of patients is additive. The MAC of xenon is in the range of the values that were predicted in a previous study.

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Background: Because the ear and mandible develop from the first and second branchial arches and first branchial cleft, abnormalities of the ear may be a sign that intubation will be difficult. We hypothesized that children with microtia would have a greater incidence of difficult laryngeal visualization with conventional rigid laryngoscopy compared to those with normal facial anatomy. Methods: We enrolled 93 consecutive school-aged patients with microtia undergoing the first stage of total reconstruction of the auricle. Age-matched patients with normal facial anatomy served as controls. Each patient was examined for the presence or absence of the five dysmorphic features of hemifacial microsomia: orbital asymmetry, mandibular hypoplasia, ear deformity, nerve involvement, soft tissue deficiency (OMENS classification). After a standardized induction of anaesthesia, the laryngeal view during rigid laryngoscopy was graded. Results: The incidence of difficult laryngeal view was 42% in the patients with bilateral microtia, 2% in those with unilateral microtia and 0% in the controls. Conclusions: There was a strong positive correlation between the number of involved abnormal anatomical components according to the OMENS classification and the degree of difficult visualization of the larynx in patients with both bilateral and unilateral microtia (Spearman rank order correlation coefficient = 0.85 and 0.88, respectively).

DOI： 10.1046/j.1460-9592.2001.00683.x

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Heparin coating of cardiopulmonary bypass (CPB) circuitry may attenuate the platelet consumption associated with CPB. We investigated the effect of temperature on the interaction between platelet and heparin coated surfaces under in vitro static conditions. Heparin coated and non coated oxygenator fibers were incubated with heparinized whole blood at 37°C and 22°C. The incubation time was set at 30, 60, 180, and 300 minutes. The number of platelets adhering to each fiber was assessed with enzyme immunoassay using monoclonal antibody against platelet receptor protein CD 61(GPIIbIIIa). As an index of platelet activation, plasma soluble(s) P-selectin levels were measured by enzyme-linked immunosorbent assay. Under normothermia, the number of adherent platelets on the non coated surface increased significantly after 300 min of incubation. Platelet adhesion was reduced significantly by heparin coating of the surface and was kept constant after 300 min. Under hypothermia, heparin coating was also associated with significant reduction of platelet adhesion. The levels of sP-selectin did not correlate with the extent of platelet adhesion. Our results suggest that heparin coating is effective in decreasing platelet adhesion to the synthetic surface tested regardless of the temperature under static conditions. Inhibition of platelet activation on the heparin coated surface may be masked by standard dose heparinization.

DOI： 10.1097/00002480-200107000-00013

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Background: The minimum alveolar concentration (MAC)awake is a traditional index of hypnotic potency of an inhalational anesthetic. The MAC-awake of xenon, an inert gas with anesthetic properties (MAC = 71%), has not been determined, It is also unknown how xenon interacts with isoflurane or sevoflurane on the MAC-awake.
Methods: In the first part of the study, 90 female patients received xenon, nitrous oxide (N2O), Isoflurane, or sevoflurane supplemented with epidural anesthesia (n = 36 for xenon and n = 18 per group for other anesthetics). In the second part, 72 additional patients received either xenon or N2O combined with the 0.5 times MAC-awake concentration of isoflurane or sevoflurane (0.2% and 0.3%, respectively, based on the results of the first part; n = 18 per group). During emergence, the concentration of an assigned anesthetic (xenon or N2O only in the second part) was decreased in 0.1 MAC decrements every 15 min from 0.8 MAC or from 70% in the case of N2O until the patient followed the command to either open her eyes or to squeeze and release the investigator's hand. The concentration midway between the value permitting the first response to command and that just preventing it was defined as the MAC-awake,
Results: The MAC-awake were as follows : xenon, 32.6 +/- 6.1% (mean +/- SD) or 0.46 +/- 0.09 MAC; N2O, 63.3 +/- 7.1% (0.61 +/- 0.07 MAC); isoflurane, 0.40 +/- 0.07% (0.35 +/- 0.06 MAC); and sevoflurane, 0.59 +/- 0.10% (0.35 +/- 0.06 MAC). Addition of the 0.5 MAC-awake concentrations of isoflurane and sevoflurane reduced the MAC-awake of xenon to 0.50 +/- 0.15 and 0.51 +/- 0.16 times its MAC-awake as a sole agent, but that of N2O to the values significantly greater than 0.5 times its MAC-awake as a sole agent (0.68 +/- 0.12 and 0.66 +/- 0.14 times MAC-awake; P &lt; 0.01, analysis of variance and Dunnett's test).
Conclusions: The MAC-awake of xenon is 33% or 0.46 times its MAC. In terms of the MAC-fraction, this is smaller than that for N2O but greater than those for isoflurane and sevoflurane. Unlike N2O, xenon interacts additively with isoflurane and sevoflurane on MAC-awake.

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The bispectral index (BIS) is derived empirically from the electroencephalogram database of patients receiving common anaesthetics, but it may not be valid for uncommon agents. Therefore, we investigated how xenon affects the BIS. Nine and I I patients were anaesthetized with 0.8 of the minimal alveolar concentration (MAC) of isoflurane (0.92%) and xenon (56%), respectively. After the end of operation, these concentrations were decreased in decrements of 0.1 MAC (isoflurane 0.12% or xenon 7%) and each new concentration was maintained for 15 min. This was repeated until the patient first opened her eyes or squeezed the investigator's hand on command. Isoflurane and xenon at 0.8 MAC reduced the BIS to a median of 40 (range 36-53) and 36 (30-61), respectively. With decreasing concentrations of isoflurane, the BIS increased progressively and it reached a median of 96 (90-98) when the patients awoke. In contrast, four patients receiving xenon responded to verbal command while the BIS was below 50 [median 45 (range 41-49)]. The remaining seven patients in the xenon group awoke when their BIS was greater than 80 [median 96 (range 82-98)], but in four of them the BIS was no greater than 50 when the xenon concentration was only 0.1 MAC (7%) higher than that associated with awakening. We conclude that low BIS values (&lt;50) do not guarantee adequate hypnosis during xenon anaesthesia.

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Study Objectives: To clarify the effect of xenon on the autonomic nervous system by comparing similar effects of isoflurane and nitrous oxide.
Design: Prospective, randomized study.
Setting: Operating room at a university hospital.
Patients: 39 ASA physical status I and II patients scheduled for general anesthesia.
Interventions: Patients were randomly allocated into one of three groups and received one of the following inhalational anesthetics: 56% of xenon (Group X), 0.94% of isoflurane (Group I), or 70% of nitrous oxide and 0.15% of isoflurane (Group N). Phenylephrine (pressor test) and nicardipine (depressor test) were given to assess baroreflex sensitivity.
Measurements and Main Results: Continuous blood pressure (BP) and electrocardiogram (ECG) were recorded before and during anesthesia to analyze heart rate (HR) variability and baroreflex sensitivity. Power spectrum of HR variability was calculated by fast Fourier transformation and power spectrum densities at low frequency (LF: 0.04- 0.15Hz) and high frequency (HF: 0.15-0.40 Hz) were compared. Baroreflex sensitivity was calculated from the slope of regression for BP changes versus associated changes in R-R intervals. For HR variability, Group X showed lower power spectrum densities (ms(2).Hz(-1)) in LF and HF than did Group I (LF: 0.09 +/- 0.06 vs. 0.35 +/- 0.53; p &lt; 0.05; HF: 0.40 +/- 0.34 vs. 0.98 +/- 0.68, p &lt; 0.01). Group X had the lowest baroreflex sensitivity (ms.mmHg(-1)) via pressor test of the three study groups (Group X: 2.00 +/- 0.87, Group I: 3.53 +/- 2.14, Group N: 3.78 +/- 2.17, p &lt; 0.05).
Conclusions: Xenon depressed both sympathetic and parasympathetic transmission more than isoflurane at 0.8 MAC. Xenon was also suggested to be relatively vagotonic. (C) 2000 by Elsevier Science Inc.

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Background: Although anesthesia with xenon has been supplemented with fentanyl, its requirement has not been established. This study was conducted to determine the plasma concentrations of fentanyl necessary to suppress somatic and hemodynamic responses to surgical incision in 50% patients in the presence of 0.7 minimum alveolar concentration (MAC) xenon.
Method: Twenty-five patients were allocated randomly to predetermined fentanyl concentration between 0.5 and 4.0 ng/ml during 0.7 MAC xenon anesthesia. Fentanyl was administered using a pharmacokinetic model-driven computer-assisted continuous infusion device. At surgical incision each patient was monitored for somatic and hemodynamic responses. A somatic response was defined as any purposeful bodily movement. A positive hemodynamic response was defined as a more than 15% increase in heart rate or mean arterial pressure more than the preincision value. The concentrations of fentanyl to prevent somatic and hemodynamic responses in 50% of patients were calculated using logistic regression.
Results: The concentration of fentanyl to prevent a somatic response to skin incision in 50% of patients in the presence of 0.7 MAC xenon was 0.72 +/- 0.07 ng/ml and to prevent a hemodynamic response was 0.94 +/- 0.06 ng/ml.
Conclusions: Comparing these results with previously published results in the presence of 70% nitrous oxide, the fentanyl requirement in xenon anesthesia is smaller than that in the equianesthetic nitrous oxide anesthesia.

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Study Objective: To understand anesthesiologists' and surgeons' risk attitudes about expected years of life.
Design: Prospective study.
Setting: Central operating rooms (ORs) in a university hospital.
Respondents: 122 anesthesiologists and surgeons.
Measurements and Main Results: A 7-page survey questionnaire regarding the length of survival and the choice of treatments was sent to 122 physicians. Certainty equivalents and Arrow-Pratt coefficients of absolute risk aversion (APC) were calculated from the survey. Of 122 physicians, 93 responded (38 anesthesiologists and 55 surgeons; response rare 76.2%). There was no significant difference in risk attitudes between the anesthesiologists and the surgeons. Their age was a statistically significant predictor of the risk attitudes: the older they were, the greater their APCs were (i.e., the more risk averse they were). There was no significant difference between gentler in risk attitudes, nor was there arty significant difference between the risk attitudes of becoming patients and those of working in the OR.
Conclusions: Physicians' risk attitudes cannot De predicted Dy their specialties or gender However, the older they are, the more risk-averse they are.

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Sevoflurane may be associated with a high incidence of emergence agitation in preschool children. We tested the hypothesis that maintenance of anesthesia with propofol after sevoflurane induction would reduce the incidence of this excitatory behavior compared with continuing sevoflurane for maintenance. We conducted a randomized, single-blinded, two-period, cross-over study in 16 preschool age children undergoing repeated brief general anesthetics for eye examination. After sevoflurane induction, patients were randomly assigned to receive either sevoflurane or propofol anesthesia for maintenance. The alternative anesthetic was used for the maintenance of anesthesia on the second occasion. We compared the speed and quality of recovery characteristics of these anesthetics, as well as, overall parent satisfaction with anesthesia. Eight patients first received sevoflurane and the remaining eight patients first received propofol. Of the patients who received sevoflurane for the maintenance of anesthesia, 38% developed emergence agitation. In contrast, none developed emergence agitation when propofol was administered for maintenance of anesthesia. Despite emergence agitation, sevoflurane provided a shorter postanesthesia care unit stay than propofol. Parent satisfaction with anesthesia was greater with propofol than with sevoflurane.

DOI： 10.1213/00000539-200009000-00012

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Study Objective: To determine the cost of xenon (Xe) anesthesia in relation to the anesthetic duration by conducting a cost analysis of this relatively expensive inhaled anesthetic.
Design: Cost analysis based on the literature on Xe anesthesia.
Setting: Anesthetic simulation based on data obtained in the operating rooms at a university hospital.
Patients: A 40-year-old ASA physical status I adult patient model weighing 70 kg; undergoing elective minor surgery with endotracheal intubation and mechanical ventilation.
Interventions: Anesthesia was given in the following four techniques: 1) closed-circuit technique with Xe; 2) closed-circuit technique with nitrous oxide (N2O)-isoflurane; 3) semiclosed technique with N2O-isoflurane; and 4) semiclosed technique with N2O-sevoflurane.
Measurements and Main Results: Cost of each anesthetic technique was compared in U.S. dollars. The cost of Xe anesthesia was consistently higher than that of N2O-isoflurane or N2O-sevoflurane (for 240-min anesthesia; $356 with Xe, $52 with closed-circuit N2O-isoflurane, $94 with semiclosed N2O-isoflurane, and $84 with semiclosed N2O-sevoflurane). The major cost of Xe anesthesia was a result of the cost of priming and flushing; the cost of Xe used for its anesthetic effects was comparable with the other semiclosed techniques after 240 minutes.
Conclusions: For Xe to be widely used in routine anesthesia, the methods of minimizing the amount of Xe necessary for priming and flushing must be developed. (C) 1999 by Elsevier Science Inc.

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Background: Nitrous oxide limits intraoperative hypothermia because the vasoconstriction threshold with nitrous oxide is higher than with equi-minimum alveolar concentrations of sevoflurane or isoflurane, presumably because of its stimulating actions on the sympathetic nervous system. Xenon, in contrast, does not cause sympathetic activation. Therefore, the authors tested the hypothesis that the vasoconstriction threshold during xenon-isoflurane anesthesia is less than during nitrous oxide-isoflurane anesthesia or isoflurane alone.
Methods: Fifteen patients each. were randomly assigned to one of three 1-minimum alveolar concentration anesthetic regimens: (1) xenon, 43% (0.6 minimum alveolar concentration) and isoflurane, 0.5% (0.4 minimum alveolar concentration); (2) nitrous oxide, 63% (0.6 minimum alveolar concentration) and isoflurane 0.5%; or (3) isoflurane, 1.2%. Ambient temperature was maintained near 23 degrees C and the patients were not actively warmed. Thermoregulatory vasoconstriction was evaluated using forearm-minus-fingertip, skin temperature gradients. A gradient exceeding 0 degrees C indicated significant vasoconstriction. The core-temperature threshold that would have been observed if skin had been maintained at 33 degrees C was calculated from mean skin and distal esophageal temperatures at the time of vasoconstriction.
Results: The patients' demographic variables, preinduction core temperatures, ambient operating room temperatures, and fluid balance were comparable among the three groups. heart rates were significantly less during xenon anesthesia than with nitrous oxide. The calculated vasoconstriction threshold was lowest with xenon (34.6 +/- 0.8 degrees C, mean +/- SD), intermediate with isoflurane alone (35.1 +/- 0.6 degrees C), and highest with nitrous oxide (35.7 +/- 0.6 degrees C). Each of the thresholds differed significantly.
Conclusions: Xenon inhibits thermoregulatory control more than isoflurane, whereas nitrous oxide is the least effective in this respect.

DOI： 10.1097/00000542-199909000-00011

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Background The authors' previous study demonstrated that xenon (Xe) and nitrous oxide (N2O) in combination with sevoflurane can attenuate cardiovascular responses to skin incision. To quantitatively evaluate their suppressive effects on cardiovascular responses, the authors compared the MAC-BAR (minimum alveolar concentration that blocks adrenergic or cardiovascular response to incision) values of sevoflurane when administered with Xe or N2O.
Methods: Forty-three patients received sevoflurane with one of three anesthetics; 1 MAC Xe, 0.7 MAC Xe and 0.7 MAC N2O. The MAC-BAR of sevoflurane was determined in each anesthetic using the "up and down" method. The response was considered positive if the heart rate or mean arterial pressure increased 15% or more. The end-tidal sevoflurane concentration given to the next patient was increased or decreased by 0.3 MAC if the response was positive or negative in the previous patient, respectively. The MAC-BAR was calculated as the mean of four independent cross-over responses.
Results: The MAC-BAR of sevoflurane, including the contribution of Xe or N2O, was 2.1 +/- 0.2 MAC and 2.7 +/- 0.2 MAC when administered with 1 MAC and 0.7 MAC Xe, respectively, and 2.6 +/- 0.4 MAC when administered with 0.7 MAC N2O (mean +/- SD).
Conclusions: Although 1 MAC Xe has a more potent suppressive effect on cardiovascular responses to incision than 0.7 MAC Xe or N2O, Xe and N2O have a similar suppressive effect at 0.7 MAC.

DOI： 10.1097/00000542-199908000-00009

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Study Objective: To determine whether pulse wave velocity (PWV), which is a useful indicator of cardiovascular disease can predict the hemodynamic responses to anesthesia and surgical stimulation in surgical patients.
Design: Prospective randomized study.
Setting: Operating rooms at a university hospital. Patients: 30 ASA physical status I and II female patients presenting for elective gynecologic surgery.
Intervention: Patients who received one of the following anesthesia techniques we-re studied; isoflurane sevoflurane and sevoflurane with nitrous oxide (N2O).
Measurements and Main Results: Patients underwent preoperative PWV measurements using an automatic PWV measurement device. Systolic blood pressure and heart rate levels were recorded at baseline, during anesthesia, and at skin incision. PWV had no significant correlation with percent changes of systolic blood pressure or heart rate even after controlling the choice of anesthetic drugs.
Conclusions: Preoperative PWV fails to predict hemodynamic responses to anesthesia and to surgical stimulation, (C) 1999 by Elsevier Science Inc.

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Study Objectives: To compare the respiratory depressant effects of propofol and sevoflurane used to facilitate the placement of the cuffed oropharyngeal airway (COPA), and to evaluate the effectiveness of the COPA in supporting positive pressure ventilation during anesthetic-induced apnea. Design: Randomized, single-blinded study. Setting: University hospital. Patients: 60 ASA physical status I and II adult patients scheduled for elective surgery with general anesthesia. Interventions: Patients were induced either with spontaneous inhalation of 5% sevoflurane or with propofol 2.0 mg/kg intravenously (IV) followed by a continuous infusion of 170 μg kg-1 min-1. If the propofol patient had a tight jaw in 90 seconds, additional propofol (0.5 mg/kg) was administered and the infusion rate was increased to 200 μg kg-1 min-1. The COPA was placed as soon as the jaw was sufficiently relaxed to allow its insertion into the mouth. Measurements and Main Results: The median (range) times to the COPA placement were 90 seconds (30 to 150 sec) and 120 seconds (60 to 210 sec) with propofol and sevoflurane, respectively (p = 0.07, Mann-Whitney U-test). Unacceptable responses to the placement (3 or more coughs, vigorous or persistent [> 30 sec] movements) occurred in 23% and 17% of those who received propofol and sevoflurane, respectively, (p = 0.35, Chi-square test). All these responses were easily suppressed by additional doses of the assigned induction drug. After placement of the COPA, 53% (16/30) of the propofol patients had apnea lasting at least 30 seconds. Notably, the positive airway Pressure at which a leak occurred in the mouth (pharyngeal leak pressure) was lower during this propofol-induced apnea than after the return of spontaneous breathing [9 (5 to 20) cmH2O vs. 15 (5 to 20) cmH2O, p < 0.01, Wilcoxon's signed-rank test]. In contrast, at no time were the sevoflurane patients apneic, and their pharyngeal leak pressure immediately following the placement was 12 (10 to 20) cmH2O. Conclusions: Propofol and sevoflurane are equally effective in facilitating the placement of the COPA. However, propofol often induces apnea, which is complicated by a less effective seal of the airway by the COPA against positive pressures. Because sevoflurane induction allows spontaneous respiration to continue and provides an adequate pharyngeal seal immediately following the placement of the COPA, it may be advantageous when apnea is not desired.

DOI： 10.1016/S0952-8180(99)00037-9

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The formalin test is an animal model of persistent pain. Although biphasic behavioral responses to formalin injection have been well described, the significance of the biphasic time course of the pain behaviors has not been established. To explore the significance of the behavioral responses to the formalin injection, we measured and analyzed cortical electrorncephalogram (EEG) during the formalin tests in rats. Formalin was injected subcutaneously in the hindpaw of freely moving rats, and behavioral responses were visually counted and recorded. Results were compared with a control group which received saline injection. Neoeortical EEG was recorded from implanted dural surface electrodes and analyzed using a Fast Fourier Transformation. Formalin produced biphasic pain behaviors with a transient pause between two phases. Cortical EEG recordings showed a biphasic change; a vigilant pattern (a low amplitude high frequency activity) followed by a non-vigilant pattern (a high amplitude low frequency activity), showing a good correlation with apparent arousal states of rats. Observed discrepancies between pain behaviors and EEG-measured vigilance stages included (1) a vigilant EEG pattern persisted during the transient pause of pain behavior, and (2) pain behaviors persisted even after non-vigilant EEG pattern became dominant. The results of the current study showed that there are temporal discrepancies between the pain behaviors and EEG-measured vigilance during the formalin test in rats. The temporal relationship between the 'pain' behaviors and nociception per se may not be as solid as believed. (C) 1999 International Association for the Study of Pain. Published by Elsevier Science B.V.

DOI： 10.1016/S0304-3959(98)00213-9

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Platelet dysfunction is one of the most important factors contributing to a postoperative hemorrhagic diathesis in children with congenital heart disease undergoing operations requiring cardiopulmonary bypass (CPB). However, very little is known about the influence of CPB on platelets in neonates and young infants. We studied 16 patients-8 young infants (<2 mo old) and 8 children (>12 mo old)-with congenital heart disease undergoing CPB. Surface density of an important platelet adhesive receptor, glycoprotein lb, and degree of platelet activation, indicated by p-selectin positivity, were measured by whole blood flow cytometry in samples obtained at seven time points during the operations. We found that the percentage of p-selectin- positive platelets increased significantly in children, but not in young infants, during CPB. The young infant group exhibited a significantly smaller reduction of glycoprotein Ib than the child group during CPB (21.0% ± 12.0% vs 32.7% ± 18.1%; P < 0.05). Lack of CPB-induced increase of p-selectin and a smaller decrease of glycoprotein lb in young infants in the current study suggest reduced platelet reactivity in young infants and neonates during CPB. The clinical significance of the reduced platelet reactivity in young infants and neonates remains to be determined. Implications: Platelets of young infants are less reactive than those of children during cardiopulmonary bypass, as determined by the cardiopulmonary bypass-induced alterations in platelet membrane adhesive receptors.

DOI： 10.1097/00000539-199902000-00006

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Background: The authors evaluated the hemodynamic suppressive effects of xenon in combination with sevoflurane at skin incision in patients undergoing surgery.
Methods: Forty patients were assigned randomly to receive one of the following four anesthetics: 1.3 minimum alveolar concentration (MAC) sevoflurane, 0.7 MAC xenon with 0.6 MAC sevoflurane, 1 MAC xenon with 0.3 MAC sevoflurane, or 0.7 MAC nitrous oxide with 0.6 MAC sevoflurane (n = 10 each group). Systolic blood pressure and heart rate mere measured before anesthesia, before incision, and approximately 1 min after incision.
Results: The changes in hemodynamic variables in response to incision mere less with sevoflurane in combination with xenon and nitrous oxide than with sevoflurane alone. Changes in heart rate (in beats/min) were 19 +/- 11 (+/- SD) for sevoflurane alone, 11+/-6 for 0.7 MAC xenon-sevoflurane, 4 +/- 4 for 1 MAC xenon-sevoflurane, and 8 +/- 7 for nitrous oxide-sevoflurane. Changes in systolic blood pressure were 35 +/- 18 mmHg for sevoflurane alone, 18 +/- 8 mmHg for 0.7 MAC xenon-sevoflurane, 16 +/- 7 mmHg for 1 MAC xenon-sevoflurane, and 14 +/- 10 mmHg for nitrous oxide-sevoflurane.
Conclusions: Xenon and nitrous oxide in combination with sevoflurane can reduce hemodynamic responses to skin incision compared with sevoflurane alone. One probable explanation may be that xenon has analgesic properties similar to those of nitrous oxide, although the exact mechanism is yet to be determined.

DOI： 10.1097/00000542-199902000-00013

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Background The anesthetic gas xenon has distinctly different physical properties compared with air, nitrous oxide, or oxygen. This led us to predict that xenon would affect the performance of commercially available flowmeters.
Methods: Flow was generated by an anesthesia ventilator connected to a lung simulator via a semiclosed breathing circuit. With the system filled with air or with various concentrations of xenon or nitrous oxide in a balance of oxygen, the tidal volume was measured with two rotating vanes, a Pitot tube, a variable-orifice flowmeter, and two constant-temperature hot-wire flowmeters.
Results: Although xenon minimally affected both rotating vane flowmeters, it caused the Pitot tube and the variable-orifice flowmeters to overread in proportion to the square root of the density of the gas mixture used (xenon is 4.6 times more dense than air). In contrast, the hot-wire anemometers underread with xenon; for example, their readings in the presence of 45% and 70% xenon were less than 10% of those displayed when air was used. Nitrous oxide minimally affected all the flowmeters except the variable-orifice device. The Pitot flowmeter was also affected, but only when its gas analyzer port was open to the ambient air so that it no longer corrected its readings for changes in gas composition. In these cases, nitrous oxide produced overreadings in the same manner as did xenon.
Conclusion: Among the four types of flowmeters studied, only the rotating-vane type is sufficiently accurate for use during anesthesia with xenon.

DOI： 10.1097/00000542-199902000-00032

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We sought to determine the anesthetic duration of sevoflurane required to achieve good conditions for placement of a cu fled oropharyngeal airway (COPA) or a laryngeal mask airway (LMA). Forty adult ASA physical status I or II patients presenting for elective surgery received single-breath vital capacity inhaled induction with 5% sevoflurane via face mask; thereafter, ventilation was manually assisted. The patients were randomized to receive either a COPA or LMA placement. The time of anesthetic exposure was varied for consecutive patients using the staircase method. The mean (95% confidence interval) anesthetic time required for acceptable COPA placement (100 [55- 145] s) was significantly shorter than that for LMA (160 [101-219] s). The 50% and 95% effective doses (from logistic analyses) for acceptable conditions associated with COPA or LMA placement were 90 s and 145 s or 164 s and 261 s, respectively. These findings suggest that COPA insertion is less stimulating than the LMA. Implications: The cuffed oropharyngeal airway is a new airway device that is similar to a laryngeal mask airway in many ways. However, it requires shorter anesthetic duration for successful placement, which suggests that it can be placed with less stimulation. It may be an alternative to a laryngeal mask airway.

DOI： 10.1097/00000539-199807000-00030

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Study Objectives: To compare acceleromyography (AMG) and electromyography (EMG) with xenon or sevoflurane anesthesia during vecuronium-induced neuromuscular blockade. Design: Prospective randomized study. Setting: University hospital. Patients: 28 ASA physical status I and II adult patients presenting for elective surgery. Interventions: Patients received vecuronium for neuromuscular blockade and either xenon (n = 11) or sevoflurane (n = 17) anesthesia. Measurements and Main Results: The first twitch depression, which was expressed as a ratio of the first twitch to that obtained before the blocking drug was administered (T1/Tc), was measured simultaneously by AMG and EMG. T1/Tc as measured by AMG consistently demonstrated greater depression than that by EMG during recovery. The limits of agreement were unacceptably wide, suggesting that T1/Tc obtained by AMG is a poor predictor of T1/Tc as measured by EMG. Such relations were not affected by the anesthetic (xenon or sevoflurane) used. Conclusion: AMG and EMG cannot be used interchangeably with either xenon or sevoflurane anesthesia.

DOI： 10.1016/S0952-8180(98)00006-3

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We have compared the differences between end-tidal PE'(CO2) and arterial Pa(CO2) carbon dioxide partial pressures during general anaesthesia using either a cuffed oropharyngeal airway (COPA) or a tracheal tube (TT) in spontaneously breathing adult patients. After induction of anaesthesia, a COPA was inserted in 20 patients who were allowed to breathe spontaneously. When steady state was reached, PE'(CO2) and Pa(CO2) were recorded. The COPA was removed, the trachea intubated with a TT and spontaneous ventilation allowed to resume. After a stable PE'(CO2) was reestablished, Pa(CO2) was measured again and PE'(CO2) recorded. Mean difference between with the COPA was 0.72 (SD 0.45) kPa and with the TT 0.64 (0.40) kPa (ns; paired t test). Our results suggest that PE'(CO2) indicator of Pa(CO2) in adults breathing spontaneously via a COPA.

DOI： 10.1093/bja/80.2.253

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：PROF SCI PUBL  

The blood-gas partition coefficients of xenon, reported more than 25 yr ago in the literature, vary considerably from 0.13 to 0.20. Consequently, we have determined this variable by directly injecting xenon-saturated blood into a gas chromatograph-mass spectrometer. This technique yielded a blood-gas partition coefficient for xenon of 0.115 (95% confidence interval 0.107-0.123). The solubility in water measured identically was 0.096, consistent with the reported value of 0.085. These data and a detailed review of the literature strongly suggest that the blood-gas partition coefficient of xenon may be lower than the generally accepted value of 0.14.

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Twitch response using accelerometry and plasma concentrations of vecuronium and its metabolite were studied in 27 surgical patients during xenon or sevoflurane anaesthesia after administration of vecuronium 0.05 mg kg(-1). Anaesthesia was maintained using oxygen-xenon (MAC=71%) or oxygen-sevoflurane (MAC=2%) at an end-tidal concentration equal to 0.8 MAC (i.e. 57% xenon and 1.6% sevoflurane). Mean time from administration of vecuronium to 25% recovery of the first twitch of the train-of-four response was significantly shorter in the xenon group than in the sevoflurane group (12.9 (so 2.5) min vs 19.4 (6.0) min, respectively). Plasma concentrations of vecuronium at 25% recovery were significantly higher during xenon than during sevoflurane anaesthesia (187 (49) ng ml(-1) vs 136 (40) ng ml(-1), respectively), while those of 3-desacetylvecuronium were similar in both groups.

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DOI： 10.1097/00000542-199806000-00036

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：PROF SCI PUBL  

Xenon (MAC=71%) has an extremely low blood:gas partition coefficient (0.14). Therefore, we predicted that the rate of emergence from xenon anaesthesia would not be affected greatly by duration of anaesthesia. We studied 54 ASA I-II patients undergoing lower abdominal surgery who received equal MAC anaesthesia with 60% xenon, 60% nitrous oxide with 0.5% isoflurane or 60% nitrous oxide with 0.7% sevoflurane (n=18 per group), each supplemented with extradural mepivacaine anaesthesia. Duration of anaesthesia was 58-380 min. At the end of operation, all inhalation anaesthetics were discontinued and patients were allowed to wake up while breathing oxygen spontaneously. A blinded investigator recorded the time until patients opened their eyes on command (T1), were judged ready for tracheal extubation (T2), could correctly state their name, date of birth and name of the hospital (T3), and could count backwards from 10 to 1 in less than 15 s (T4). Emergence times after xenon and nitrous oxide-sevoflurane anaesthesia did not correlate with duration of anaesthesia, whereas those from nitrous oxide-isoflurane had positive correlations. Mean emergence times from xenon anaesthesia were: T1, 3.3 (SD 1.0) min; T2, 3.6 (1.0) min; T3, 5.0 (1.1) min; and T4, 6.2 (1.7) min. These values were approximately 50% of those after nitrous oxide-sevoflurane anaesthesia (T1, 5.6 (1.4) min; T4, 10.5 (2.0) min). We conclude that xenon provided fast emergence from anaesthesia, regardless of the duration of anaesthesia.

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：MUNKSGAARD INT PUBL LTD  

Background: Xenon is an odorless gas with low blood-gas solubility coefficient and without occupational and environmental hazards. This investigation was performed to evaluate the speed of induction, and respiratory and cardiovascular reactions to inhalation induction with xenon compared to an equianesthetic concentration of sevoflurane.
Method: Twenty-four adult ASA 1-2 patients premedicated with 0.05 mg/kg of midazolam were instructed to take vital capacity breaths of 1 minimum alveolar concentration (MAC) of either xenon or sevoflurane until they lost consciousness. Induction time, total ventilatory volume, tidal volume, respiratory rate, minute ventilation, end-tidal MAC fraction, cardiovascular parameters and oxygen saturation were recorded. The patients were interviewed on the following day to evaluate their ac ceptability rating of the inhalation inductions.
Results: Compared to equianesthetic sevoflurane, xenon produced a faster induction of anesthesia (147+/-59 versus 71+/-21 s, respectively) with smaller decreases in respiratory rate, tidal volume and minute ventilation. Both agents showed comparable cardiovascular stability and oxygen saturation during induction. One patient in the sevoflurane group had breath-holding and movements of extremities and another had only breath-holding. No patients in the xenon group experienced any complications.
Conclusion: Xenon produced a faster induction of anesthesia without any complications than sevoflurane. Xenon had smaller decreases in tidal volume and respiratory rate during induction than sevoflurane. Xenon might offer an alternative to sevoflurane for an inhalation induction. (C) Acta Anaesthesiologica Scandinavica 41 (1997).

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：LIPPINCOTT-RAVEN PUBL  

Background: Xenon, an inert gas with anesthetic properties (minimum alveolar concentration [MAC] = 71%), has an ex tremely low blood:gas partition coefficient (0.14). Therefore, we predicted that xenon would provide more rapid emergence from anesthesia than does N2O+isoflurane or N2O+sevoflurane of equivalent MAC.
Methods: Thirty American Society of Anesthsiologists class I or II patients undergoing total abdominal hysterectomy were randomly assigned to receive 60% xenon, 60% N2O+0.5% isoflurane, or 60% N2O+0.7% sevoflurane (all concentrations are end-tidal: n = 10 per group). After placement of an epidural catheter, anesthesia was induced with standardized doses of midazolam, thiopental, and fentanyl, Thirty minutes later, xenon, N2O+isoflurane, or N2O+sevoflurane was started as previously assigned. These regimens were supplemented with epidural anesthesia with mepivacaine so that the mean arterial pressure and heart rate were controlled within 20% of the preoperative values, At the end of operation lasting approximately 2 h, all inhalational anesthetics were discontinued, and the patients were allowed to awaken while breathing spontaneously on an 8 l/min inflow of oxygen. A blinded investigator recorded the time until the patient opened her eyes on command (T1), was judged ready for extubation (T2), could correctly state her name, her date of birth, and the name of the hospital (T3), and could count backward from 10 to 1 in less than 15 s (T4).
Results: Emergence times from xenon anesthesia were: T1, 3.4 +/- 0.9 min; T2, 3.6 +/- 1 min; T3, 5.2 +/- 1.4 min; and T4, 6.0 +/- 1.6 min (mean +/- SD). These were one half to one third of those from N2O+sevoflurane (T1, 6.0 +/- 1.7 min; T4, 10.5 +/- 2.5 min) or N2O+isoflurane (T1, 7.0 +/- 1.9 min; T4, 14.3 +/- 2.8 min) anesthesia. The three groups did not differ in terms of patient demographics, the duration of anesthesia, the amount of epidural mepivacaine administered, or the postoperative pain rating. No patient could recalls intraoperative events.
Conclusions: Emergence from xenon anesthesia is two or three times faster than that from equal-MAC N2O+isoflurane or N2O+sevoflurane anesthesia.

DOI： 10.1097/00000542-199706000-00007

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BLACKWELL SCIENCE INC  

Xenon is an inert gas with a practical anesthetic potency (1 MAC = 71%). Because it is very expensive, the use of closed circuit anesthesia technique is ideal for the conduction of xenon anesthesia. Here we describe our methods of starting closed circuit anesthesia without excessive waste of xenon pas. We induce anesthesia with intravenous agents, and after endotracheal intubation, denitrogenate the patient for apa proximately 30 min with a high flow of oxygen. This is done to minimize accumulation of nitrogen in the anesthesia circuit during the subsequent closed-circuit anesthesia with xenon. Anesthesia is maintained with an inhalational anesthetic during this period. Then, we discontinue the inhalational agent and start xenon. For this transition, we feel it is unacceptable to simply administer xenon at a high flow until the desired end-tidal concentration is reached because it is too costly. Instead, we set up another machine with its circuit filled in advance (i.e., primed) with at least 60% xenon in oxygen and switch the patient to this machine. To prime the circuit, we push xenon using a large syringe into a circuit, which was prefilled with oxygen. Oxygen inside the circuit is pushed out before it is mixed with xenon, and xenon waste will thus be minimized. In this way, we can achieve close to 1 MAC from the beginning of xenon anesthesia, and thereby minimize the risk of light anesthesia and awareness during transition from denitrogenation to closed-circuit xenon anesthesia.

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We reported previously that nitrous oxide induces pre-emptive analgesia that is partially antagonized by naloxone and totally antagonized by halothane. The aims of this study were to determine if halothane and isoflurane are similar in this respect and to examine if volatile anaesthetics antagonize the analgesic effect of exogenous opioids. We found that 75% nitrous oxide prolonged tail-flick latency by 37% and this analgesia was dose-dependently inhibited by halothane and, less effectively, by isoflurane. In contrast, morphine 1.25 mg kg(-1) i.v. also prolonged tail-flick latency by 35% but, unlike nitrous oxide-induced analgesia, this effect was attenuated only by high doses of halothane and was unaffected by isoflurane. Neither halothane nor isoflurane alone altered the tail-flick response. We conclude that both halothane and isoflurane dose-dependently antagonized nitrous oxide analgesia but antagonized morphine-induced analgesia to a lesser extent.

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Language：Japanese  

DOI： 10.2199/jjsca.15.685

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J-GLOBAL

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

70歳代、男性。胃潰瘍の止血処置後より頻呼吸、乳酸アシドーシス、ショック状態を呈したため、ICU入室となった。ICU入室後は気管挿管、人工呼吸管理、持続式血液透析濾過を導入した。その後の精査で肺高血圧を合併した衝心脚気が判明し、ビタミンB1補充を行ったところ、ショックは改善し、肺高血圧も軽快した。第8病日に抜管、ICUを退室し、第16病日に自宅退院となった。

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

67歳男性。胃癌に対するmFOLFOX療法施行中に意識障害を呈し、人工呼吸器管理下にICU入室となった。臨床経過および臨床検査所見より、5-FU投与による乳酸アシドーシス、高アンモニア血症と診断された。血液透析を導入したところ、開始数時間で乳酸アシドーシスおよび意識レベルの改善、アンモニア値の低下を認め、その後の経過は良好であった。

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

70歳代、男性。胃潰瘍の止血処置後より頻呼吸、乳酸アシドーシス、ショック状態を呈したため、ICU入室となった。ICU入室後は気管挿管、人工呼吸管理、持続式血液透析濾過を導入した。その後の精査で肺高血圧を合併した衝心脚気が判明し、ビタミンB1補充を行ったところ、ショックは改善し、肺高血圧も軽快した。第8病日に抜管、ICUを退室し、第16病日に自宅退院となった。

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Language：Japanese   Publisher：克誠堂出版(株)  

喉頭エコーは声帯麻痺の診断に有用とされており、喉頭エコーの正常像において披裂軟骨は、吸気相で外側へ動き、呼気相では内側へ動く「開閉運動」が認められ、声帯麻痺では「開閉運動」が認められないことで診断される。今回、左反回神経麻痺のある患者の喉頭エコーにおいて、披裂部の声門裂への引き込みによる異常運動(floppy arytenoid)を認め、これを「披裂軟骨の開閉運動あり」と誤認してしまった症例を経験したので、喉頭エコーのピットフォールとして報告した。

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2020&ichushi_jid=J01397&link_issn=&doc_id=20200203080005&doc_link_id=%2Fad3msuie%2F2020%2F006902%2F006%2F0143-0146%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fad3msuie%2F2020%2F006902%2F006%2F0143-0146%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

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86歳女。呼吸困難と前頸部腫脹を主訴に救急外来を受診し、頭頸部CTで気管浸潤のある甲状腺腫瘍と診断した。気管浸潤は声門の遠位20mmにある有茎性で最大径11mmの気管内腫瘍で、気管内腔の開存率は41%であった。緊急手術を行う方針でHigh care unitに入室したが2時間後に呼吸数増加、喘鳴、呼吸困難を認めた。覚醒下で内径6.0mm気管チューブを留置し、挿管後用手換気は容易であったが、気管内腫瘍が脱落した。気管チューブを腫瘍ごと抜管して摘出を試みたが、腫瘍は気管チューブから脱落した。内径8.5mm気管チューブに入れ替え、気管支鏡の処置ポートで腫瘍を吸引したまま気管支鏡を引き抜いて脱落腫瘍を回収した。その後、甲状腺腫瘍摘出術、気管切開が施行され、ICU入室を経て術後2日目に一般病棟へ転床した。

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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23歳女性。後腹膜の巨大パラガングリオーマに対して腫瘍摘出術が予定された。腫瘍が周囲臓器に浸潤している疑いがあったため、術前に関連診療科、手術室看護師、臨床工学技士との合同カンファレンスを行い、対策を検討した。結果的には単純摘出であったが、摘出後に血管拡張性ショックを認めたため、ノルアドレナリンに加えバソプレシンを投与したところ、循環動態は安定した。その後の経過は良好で、術後16日目に退院となった。

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Rett syndrome, which is a progressive, central nervous system disease that is caused by a gene mutation, is known to present with various symptoms. This case is that of a 15-year-old girl who was diagnosed with Rett syndrome at the age of 2 years. Laryngotracheal isolation under general anesthesia was planned due to recurrent aspiration pneumonia. Since the patient's nutritional status and control of convulsions were good, this was deemed an appropriate time for the surgery. Following careful preoperative evaluation of her airway, we performed oral endotracheal intubation using a video laryngoscope after rapid induction. Since postoperative pain control was important to prevent apneic attacks and convulsions, we used a multimodal analgesic regimen including carefully titrated fentanyl, acetaminophen, nonsteroidal anti-inflammatory drug, and wound infiltration with a local anesthetic. Postoperatively, the patient returned to the intensive care unit under spontaneous ventilation and followed a good course. Patients with Rett syndrome present several symptoms. Thus, several points must be considered during the preoperative evaluation, anesthetic management, and postoperative care of these patients.

DOI： 10.1186/s40981-018-0169-y

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DOI： 10.1213/XAA.0000000000000637

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DOI： 10.1213/ANE.0000000000002588

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J-GLOBAL

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Language：Japanese   Publisher：(一社)日本心臓血管麻酔学会  

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Language：Japanese   Publisher：日本手術医学会  

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Other Link： http://search.jamas.or.jp/link/ui/2017385261

Language：Japanese   Publisher：(一社)日本消化器内視鏡学会  

【目的】従来のベンゾジアゼピン系薬剤を用いた鎮静と比較して、食道ESDにおけるプロポフォール(PF)とデクスメデトミジン(DEX)を併用した鎮静の有効性と安全性について検討する。【方法】当施設で食道ESDが施行された連続40症例の臨床情報を遡及的に解析した。20例はベンゾジアゼピン系薬剤による鎮静(従来群)、20例はPF・DEX併用による鎮静(併用群)が行われた。鎮静の有効性と安全性に関する各パラメータを両群で比較した。【結果】併用群は処置時間が有意に短く(61分vs 89分、P=0.03)、抑制を要する体動が見られた患者の割合も有意に少なかった(25% vs 65%、P=0.025)。一方、併用群は低血圧(60% vs 15%、P=0.008)と徐脈(60% vs 15%、P=0.008)の発生率が有意に高かった。治療中断を要する重篤な有害事象は両群ともになかった。【結論】PFとDEXを併用した鎮静は食道ESDにおいて患者体動を抑えた安定した鎮静となり得る可能性が示唆された。(著者抄録)

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Language：Japanese   Publisher：日本臨床麻酔学会  

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Language：Japanese   Publisher：日本臨床麻酔学会  

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72歳男。高血圧緊急症のため緊急入院となった。精査の結果、右副腎の巨大褐色細胞腫と診断された。α遮断薬による内科治療後、待機的に開腹腫瘍摘出術が予定された。麻酔は全身麻酔で行った。手術中の腫瘍操作により、収縮期血圧の著明な上昇を認め、150mmHg程度にコントロールした。腫瘍摘出後、血圧と心拍数が急激に低下し、アドレナリン、ノルアドレナリンの持続投与を行うも収縮期血圧が60〜70mmHg程度にしか上昇せず、治療抵抗性であった。血管抵抗を上昇させる目的でバソプレシンの投与を開始、徐々に血圧は安定していった。ICU入室後に施行した経胸壁心臓超音波検査では、びまん性の壁運動低下を認め、末梢冷感も出現しており低心拍出量症候群と推定された。ホスホジエステラーゼIII阻害薬であるオルプリノンの投与開始により心臓の壁運動は徐々に改善した。

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61歳女。右肺癌に対して胸腔鏡下右肺上葉切除術が予定された。麻酔は全身麻酔と硬膜外麻酔で管理した。麻酔終了1時間半後、両下腿の不随意運動が数分ごとに出現すると患者の訴えがあった。硬膜外麻酔との関連を疑い、硬膜外カテーテルからの持続投与を中止した。不随意運動は徐々に出現間隔が広がり、硬膜外持続投与中止から約45分後に消失した。症状が可逆的であったことから、経過観察とした。翌朝、疼痛の訴えが強かったため、前日中止した患者管理鎮痛ポンプを用いた硬膜外持続投与を再開した。投与開始3時間半後に同様の不随意運動が出現したため持続投与を中止し、1時間半後には完全に症状が消失した。以後、症状の再出現はなく、神経学的後遺症を認めることなく第9病日に退院となった。

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Language：English   Publishing type：Research paper, summary (international conference)  

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