Intraoperative prostaglandin E1 improves antimicrobial and inflammatory responses in alveolar immune cells

OBJECTIVE

Anesthesia and surgery decrease antimicrobial and increase proinflammatory functions of alveolar immune cells. Thus, anti-inflammatory agents that do not further suppress antimicrobial functions are required. We tested the hypothesis that intraoperative prostaglandin E1 (PGE1) suppresses proinflammatory responses and prevents the reduction in antimicrobial responses of alveolar immune cells.

DESIGN

Prospective, randomized, controlled, double-blind study.

SETTING

University hospital.

PATIENTS

A total of 40 patients undergoing elective orthopedic surgery under propofol/fentanyl anesthesia.

INTERVENTION

In double-blind fashion, the patients received PGE1 from the beginning to the end of surgery (PGE1 group, n = 20) or nothing (control group, n = 20).

METHODS AND MAIN RESULTS

Alveolar immune cells were harvested by bronchoalveolar lavage immediately after induction of anesthesia; 2, 4, and 6 hrs after induction of anesthesia; and at the end of surgery. We measured opsonized and nonopsonized phagocytosis. Microbicidal activity was evaluated to directly kill Listeria monocytogenes in alveolar macrophages. Finally, we determined the expression of proinflammatory cytokines including interleukin (IL)-1beta, IL-8, interferon-gamma, and tumor necrosis factor-alpha, and that of anti-inflammatory cytokines (IL-4 and IL-10) by semiquantitative polymerase chain reaction. Nonopsonized and opsonized phagocytosis and microbicidal activity of alveolar macrophages decreased and the expression of genes for all pro- and anti-inflammatory cytokines increased significantly over time in both groups. Starting 2-4 hrs after induction of anesthesia, the increases in gene expression of proinflammatory cytokines were 1.5-3 times smaller in the PGE1 than in the control group. Starting 6 hrs after anesthesia, the increase in gene expression of IL-10 was 1.5-3 times greater in the PGE1 than in the control group. Intraoperative decreases in phagocytic and microbial activities were the same in the two groups.

CONCLUSION

Intraoperative PGE1 not only suppressed proinflammatory responses, but also protected antimicrobial functions of alveolar macrophages, possibly because PGE1 is mostly inactivated in the pulmonary intravascular space. Our results suggest that intraoperative PGE1 protects the pulmonary immune defense in alveolar immune cells.

Plasma proinflammatory cytokine response to surgical stress in elderly patients

We investigated the change of plasma cytokines concentrations in elderly patients during lower abdominal surgery. Plasma interleukin (IL-)6 concentrations (68.0+/-15.4 and 36.1+/-20.7 pg/ml) in elderly patients at 24 h and at 3 days after surgery were significantly higher than those (35.1+/-21.5 and 18.6+/-10.6 pg/ml) of young adults. Plasma IL-6 concentrations (92.3+/- 31.9 pg/ml) in elderly patients anesthetized with propofol and fentanyl were significantly higher at the end of the operation than that (57.9+/-36.7 pg/ml) of elderly patients anesthetized with sevoflurane and fentanyl. In conclusion, elderly patients have an increased and delayed IL-6 response to surgical trauma compared with young adults. Plasma IL-6 production after surgical trauma in elderly patients with total intravenous anesthesia with propofol was significantly higher than that in elderly patients with sevoflurane anesthesia.

The relationship between pneumatic tourniquet time and the amount of pulmonary emboli in patients undergoing knee arthroscopic surgeries

Near-fatal pulmonary embolism can occur immediately after tourniquet release after orthopedic surgeries. In this study, we determined the relationship between tourniquet time and the occurrence of pulmonary emboli in 30 patients undergoing arthroscopic knee surgeries, by using transesophageal echocardiography. The right atrium (RA) was continuously monitored by transesophageal echocardiography, and the number of emboli present was assessed with the following formula: Amount of emboli = 100 x [(total embolic area in the RA after tourniquet release) - (total area of emboli or artifact in the RA before tourniquet release)]/(RA area). The area was assessed 0-300 s after tourniquet release by using image-analysis software. The peak amount of emboli appeared approximately 50 s after tourniquet release. In addition, there was a significant correlation between amount of emboli (Ae [%]) and tourniquet time (Ttq [min]): (Ae = 0.1 x Ttq - 1.0, r = 0.795, P < 0.01). This study suggests that acute pulmonary embolism may occur within 1 min of tourniquet release and that the number of emboli is dependent on Ttq.

Rebound perioperative hyperkalemia in six patients after cessation of ritodrine for premature labor

IMPLICATIONS

This report describes six patients who had marked hyperkalemia 60-150 min after cessation of intravenous ritodrine, which had been administered for management of preterm labor. Abnormal electrocardiographic findings are very important clues for a prompt diagnosis of hyperkalemia.

Comparison of initial distribution volume of glucose and plasma volume in thoracic fluid-accumulated patients

OBJECTIVE

We have reported that initial distribution volume of glucose indicates the central extracellular fluid volume in the presence of fluid gain or loss. The purpose of this study was to describe changes in initial distribution volume of glucose, plasma volume determined by the indocyanine green dilution method (PV-ICG), and thoracic fluid content by thoracic electrical bioimpedance in patients with or without apparent thoracic fluid accumulation in the absence of pleural effusion. We also sought to test whether initial distribution volume of glucose rather than PV-ICG mirrors thoracic fluid content.

DESIGN

Prospective, clinical study.

SETTING

General intensive care unit.

PATIENTS

Eleven consecutive patients with apparent thoracic fluid accumulation as judged by thoracic fluid content >0.05/ohm and underlying pathology and 20 consecutive acute myocardial infarction patients within 24 hrs after its onset were selected for study. None of the acute myocardial infarction patients had thoracic fluid content >0.05/ohm.

INTERVENTIONS

Five grams of glucose and 25 mg of indocyanine green were administered simultaneously to calculate initial distribution volume of glucose and PV-ICG daily for the fluid-accumulated patients, and the same dosages were administered to the acute myocardial infarction patients immediately after their admission to the intensive care unit after percutaneous coronary angioplasty. Only the data on the day of the maximal and minimal thoracic fluid content in the fluid-accumulated patients were used for the study. The relationship between these two fluid volumes and thoracic fluid content was evaluated in the two patient groups.

MEASUREMENTS AND MAIN RESULTS

Initial distribution volume of glucose and thoracic fluid content rather than PV-ICG and thoracic fluid content moved together in the same direction in each fluid-accumulated patient. Neither pulmonary artery occlusion pressure, central venous pressure, nor PV-ICG produced a better correlation with cardiac index when compared with initial distribution volume of glucose in patients with or without thoracic fluid accumulation.

CONCLUSIONS

We suggest that initial distribution volume of glucose rather than PV-ICG is a better indicator of the intrathoracic blood volume status, even although intravenously administered glucose cannot stay in the intravascular compartment.

Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses

BACKGROUND

In a controlled and double-blind study, the authors tested the hypothesis that preoperative insertion of intradermal needles at acupoints 2.5 cm from the spinal vertebrae (bladder meridian) provide satisfactory postoperative analgesia.

METHODS

The authors enrolled patients scheduled for elective upper and lower abdominal surgery. Before anesthesia, patients undergoing each type of surgery were randomly assigned to one of two groups: acupuncture (n = 50 and n = 39 for upper and lower abdominal surgery, respectively) or control (n = 48 and n = 38 for upper and lower abdominal surgery, respectively). In the acupuncture group, intradermal needles were inserted to the left and right of bladder meridian 18-24 and 20-26 in upper and lower abdominal surgery before induction of anesthesia, respectively. Postoperative analgesia was maintained with epidural morphine and bolus doses of intravenous morphine. Consumption of intravenous morphine was recorded. Incisional pain at rest and during coughing and deep visceral pain were recorded during recovery and for 4 days thereafter on a four-point verbal rating scale. We also evaluated time-dependent changes in plasma concentrations of cortisol and catecholamines.

RESULTS

Starting from the recovery room, intradermal acupuncture increased the fraction of patients with good pain relief as compared with the control (P < 0.05). Consumption of supplemental intravenous morphine was reduced 50%, and the incidence of postoperative nausea was reduced 20-30% in the acupuncture patients who had undergone either upper or lower abdominal surgery (P < 0.01). Plasma cortisol and epinephrine concentrations were reduced 30-50% in the acupuncture group during recovery and on the first postoperative day (P < 0.01).

CONCLUSION

Preoperative insertion of intradermal needles reduces postoperative pain, the analgesic requirement, and opioid-related side effects after both upper and lower abdominal surgery. Acupuncture analgesia also reduces the activation of the sympathoadrenal system that normally accompanies surgery.

Expression and immunolocalization of AQP6 in intercalated cells of the rat kidney collecting duct

The expression and localization of AQP6 were examined in rat kidneys. In the kidney compartments, the expression was more intense in the outer medulla than in the cortex or inner medulla, and was negative in the glomerulus. During development, the AQP6 mRNA expression in the kidney was not detected in the fetus, but was recognized at birth, increased gradually by 4 weeks of age, and was unchanged thereafter. In situ hybridization demonstrated significant signals for AQP6 mRNA along the outer and inner medullary collecting ducts. Since the localization of the AQP6 mRNA-expressing cells was comparable to that of immunoreactive H+ ATPase-bearing cells in the collecting duct, they were identified as intercalated cells. No AQP6 mRNA signals were recognizable in other cells in the kidneys, including glomerular cells. No glomerular expression of AQP6 mRNA was confirmed by RT-PCR using total RNA extracted from the glomeruli. Immunohistochemistry using an antibody raised against recombinant rat AQP6 protein could localize the immunoreactivity in a population of collecting duct cells. Serial section observations indicated that the AQP6-immunoreactive cells corresponded to H+ ATPase bearing intercalated cells.

Xenon inhalation increases norepinephrine release from the anterior and posterior hypothalamus in rats

PURPOSE

To investigate the effect of xenon (Xe) and nitrous oxide (N(2)O) on norepinephrinergic neuronal activity in the rat medial preoptic area (mPOA) and posterior hypothalamus (PH) using microdialysis.

METHODS

Sixty male Wistar rats were equally allocated to two groups: mPOA and PH. A microdialysis probe was implanted into the mPOA or the PH. In both groups, each animal was exposed to one of the following inhalations: 25% oxygen (control, n=6), 30% Xe (n=6), 60% Xe (n=6), 30% N(2)O (n=6) or 60% N(2)O (n=6). Norepinephrine concentration in the perfused artificial cerebrospinal fluid was measured by high pressure liquid chromatography at ten-minute intervals. After plotting the time-norepinephrine concentration curve, the area under the curve (AUC) in each group was calculated.

RESULTS

In the mPOA, 30 and 60% Xe, but only 60% N(2)O significantly increased norepinephrine release. The AUC in the 30% Xe, 60% Xe or 60% N(2)O group was 160 +/- 9 (P <0.05), 288 +/- 42 (P <0.01) or 237 +/- 46 pg x min/sample (P <0.01), respectively, compared to that in the control group: 77 +/- 14 pg x min/sample. In the PH, only 60% Xe significantly increased norepinephrine release compared to control (AUC: 191 +/- 38 vs. 71 +/- 1 pg x min/sample, P <0.01).

CONCLUSION

The present data suggest that Xe stimulates norepinephrinergic neurons more potently than N(2)O; 1.2 times more in the mPOA and 2.5 times more in the PH. This stimulant effect may contribute to the hypnotic and sympathotonic effects of Xe in rats.

A comparison of the relaxant effects of olprinone and aminophylline on methacholine-induced bronchoconstriction in dogs

IV aminophylline, a nonselective phosphodiesterase (PDE) inhibitor, is often used to treat an asthma attack during anesthesia. However, in some instances, aminophylline-resistant attacks are observed. Selective PDE3 inhibitors are now clinically available and have been reported to produce bronchodilation. Thus, we compared the relaxant effects of olprinone, a novel PDE3 inhibitor, and aminophylline on methacholine-induced bronchoconstriction. Dogs were anesthetized with pentobarbital. Bronchoconstriction was elicited with methacholine (0.5 microg/kg + 5.0 microg. kg(-1). min(-1)) and assessed as percentage of changes in the bronchial cross-sectional area (BCA; basal = 100%) monitored by bronchoscope. Initially, the relaxant effects of olprinone (n = 8; 0-1000 microg/kg) and aminophylline (n = 8; 0-50 mg/kg) were compared. The bronchial cross-sectional areas were assessed before and 30 min after methacholine infusion began and 5 min after each dose of olprinone or aminophylline. We then determined whether propranolol (0.4 mg/kg) reversed the relaxation induced by olprinone (1000 microg/kg) and aminophylline (50 mg/kg). Olprinone and aminophylline dose-dependently antagonized bronchoconstriction by 56.2% +/- 21.3% (SD) and 68.0% +/- 30.3% with -log 50% effective dose (mean) of 4.80 +/- 0.38 (15.8) microg/kg and 1.96 +/- 0.42 (10.9) mg/kg, respectively. Aminophylline 50 mg/kg significantly increased plasma epinephrine, whereas olprinone did not. In addition, propranolol significantly reduced aminophylline-induced relaxation, but not olprinone-induced relaxation. Therefore, the relaxant effects of olprinone are independent of plasma epinephrine, whereas aminophylline effects may partially result from increased circulating concentrations of epinephrine.

IMPLICATIONS

We compared the relaxant effects of olprinone and aminophylline on methacholine-induced bronchoconstriction in dogs. The relaxant effects of olprinone are independent of plasma epinephrine, whereas the aminophylline effects may be partly caused by an increase in plasma epinephrine.

Plasma cytokine response to surgical stress in schizophrenic patients

Schizophrenic patients are reported to have immunological dysfunction, however, the immune response to surgery in schizophrenic patients remains unclear. We measured plasma interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor-alpha (TNF-alpha) before, during and after colectomy, hemicolectomy and sigmoidectomy in 25 chronic schizophrenic patients (Group S) and 25 control patients (Group C) using ELISA assays. We could find no significant difference in the baseline plasma concentrations of IL-6, IL-8 and TNF-alpha between Group S and Group C. Plasma IL-6 concentrations (32.1 (30.3) and 15.8 (9.6) pg/ml) in Group S at the end of the operation and 24 h after surgery were significantly lower than 76.9 (37.1) and 35.1 (21.5) pg/ml of Group C. Plasma IL-8 concentration (6.1 (2.8)) in Group S at the end of the operation was significantly lower than 8.7 (4.2) pg/ml of Group C. There were no significant changes in plasma TNF-alpha concentration throughout the study period in either group. Plasma cortisol concentrations of schizophrenic patients during surgery were significantly lower than those of control patients. The plasma IL-6 concentrations correlated with plasma cortisol concentrations in either group. We conclude that proinflammatory cytokine response to abdominal surgery is inhibited in schizophrenic patients.

Recovery of intraoperative microbicidal and inflammatory functions of alveolar immune cells after a tobacco smoke-free period

BACKGROUND

Tobacco smoking inhibits alveolar macrophage function, but cessation of smoking markedly reduces the risk of postoperative pulmonary complications. The authors therefore evaluated the effect of nonsmoking duration on both antimicrobial and inflammatory functions of alveolar macrophages during anesthesia and surgery.

METHODS

The authors studied 15 patients who had never smoked, 15 current smokers, and 41 former smokers, all of whom underwent general anesthesia. Former smokers were further allocated to one of three groups depending on their smoke-free periods: 2 months (n = 13), 3-5 months (n = 13), and 6-12 months (n = 15). Alveolar immune cells were collected by bronchoalveolar lavage immediately after induction of anesthesia, at 2 and 4 h after induction of anesthesia, and at the end of surgery. Opsonized and nonopsonized phagocytosis were measured. Microbicidal activity was determined as the ability of the macrophages to kill Listeria monocytogenes directly. Finally, we determined the expression of proinflammatory cytokines, including interleukin 1beta, interleukin 8, interferon gamma, and tumor necrosis factor alpha, and of antiinflammatory cytokines (interleukin 4 and 10) by semiquantitative polymerase chain reaction.

RESULTS

Nonopsonized and opsonized phagocytosis and microbicidal activity of alveolar macrophages (antimicrobial functions) decreased 20-50%, and the expression of genes for all proinflammatory and antiinflammatory cytokines increased 3-30-fold over time in all groups. Starting 4 h after induction of anesthesia, the decreases in antimicrobial functions were 1.5-3 times greater in current and former smokers (2 months' abstinence) than in patients who had never smoked. Starting 4 h after anesthesia, the increase in expression of all cytokines, except interleukin 8, was twofold to fivefold less in current and former smokers (2-6 months' abstinence) than in patients who had never smoked.

CONCLUSION

Our data suggest that former smokers may have a limited ability to mount effective pulmonary immune defenses for long as 6 months after stopping cigarette use.

Effects of isoflurane and ketamine on sleep in rabbits

The postoperative sleep disturbance (POSD) is characterized by reduction of sleep after surgical operation. However, its mechanism is not well known. Therefore, we hypothesized that anesthetics could contribute to the POSD, and studied the effects of isoflurane and ketamine on sleep in rabbits. Rabbit sleep was measured for 21 h after isoflurane exposure or intravenous injection of ketamine. Non-rapid eye movement sleep (NREMS) was decreased after isoflurane anesthesia. In contrast, ketamine anesthesia significantly enhanced NREMS. Both anesthetics did not affect rapid eye movement sleep. These results suggest that isoflurane may contribute to the POSD, but ketamine may decrease the POSD.

Ketamine and midazolam kinetics during continuous hemodiafiltration in patients with multiple organ dysfunction syndrome

OBJECTIVE

To assess the effect of continuous hemodiafiltration (CHDF) on ketamine and midazolam kinetics in multiple organ dysfunction syndrome (MODS).

DESIGN AND SETTING

Consecutive clinical study in a general intensive care unit of a university hospital.

PATIENTS

Twelve adult patients with MODS requiring CHDF.

MEASUREMENTS AND RESULTS

A total of 68 samples were collected during CHDF for ketamine, norketamine, and midazolam assays. The clearance values for ketamine and norketamine were 10.8 +/- 6.6 and 10.9 +/- 11.5 ml/min and their daily extractions were 21.4 +/- 7.1 and 10.2 +/- 11.5 mg/day, respectively. Midazolam was not eliminated through the filter during CHDF. There were no changes in Ramsay Sedation Score or Glasgow Coma Scale during CHDF.

CONCLUSIONS

Small fractions of ketamine and norketamine were eliminated during CHDF in MODS. Midazolam was not eliminated during CHDF. CHDF did not affect the sedation using ketamine and midazolam even in MODS patients.

Effects of nociceptinNH2 and [Nphe1]nociceptin(1-13)NH2 on rat brain noradrenaline release in vivo and in vitro

We have investigated the effects of nociceptin/orphanin FQ (NC) receptor agonist NCNH2 and a competitive NC receptor antagonist, [Nphe1]NC(1-13)NH2 on noradrenaline (NA) release in vivo using microdialysis in freely moving animals and in vitro from cerebrocortical slices. One nmol of NCNH2 injected into rat locus coeruleus inhibited NA release from the prefrontal cortex (E(max) 27.4+/-5.7% 30 min after injection) which was partially (33%) reversed by 100 nmol of [Nphe1]NC(1-13)NH2. In cerebrocortical slices NCNH2 inhibited NA release in a concentration-dependent manner (EC50 12 nM, E(max) 29.4%) that was reversed by [Nphe1]NC(1-13)NH2. In both preparations, [Nphe1]NC(1-13)NH2 per se was inactive. These data demonstrate an inhibition of NA release by NCNH2 in a [Nphe1]NC(1-13)NH2 sensitive manner in both in vivo brain microdialysis and in vitro cerebrocortical slices studies in rats.

Density detection in dependent left lung region using transesophageal echocardiography

BACKGROUND

Densities in dependent lung regions worsen oxygenation in patients with acute respiratory distress syndrome. Identification of these densities requires examination using computed tomography (CT). In this study, the authors evaluated the use of transesophageal echocardiography (TEE) to estimate densities in the dependent lung.

METHODS

Forty consecutive patients with acute lung injury or acute respiratory distress syndrome who underwent CT and TEE examination were included in this study. Densities in the lower left lung area were detected through the descending aorta by TEE. Density areas observed by TEE were compared with those obtained by CT. The effect of positive end-expiratory pressure (PEEP) application on density area was also evaluated.

RESULTS

Density areas in the dependent lung region measured by TEE were 12.0+/-6.1 cm2 (mean +/- SD) at mid esophageal position. Density areas evaluated using TEE in the left lung correlated significantly with those estimated with CT in the left and right lungs (P < 0.01 in both lungs). In addition, the authors observed a significant correlation between PaO2/FIO2 and density areas estimated using TEE (P < 0.05). During positive end-expiratory pressure application, the area of density estimated with TEE decreased and PaO2 improved.

CONCLUSIONS

The authors clearly demonstrated that it is possible to estimate the density area of the dependent left lung regions in patients with acute lung injury or acute respiratory distress syndrome using TEE. It is also possible to observe the changes of density areas during application of positive end-expiratory pressure.

The mechanism of cell death in human cultured colon adenocarcinoma cell line COLO 201 induced by beta-D-N-acetylglucosaminyl-p-nitrophenol

COLO 201, human colon adenocarcinoma cells were incubated with artificial primers, p-nitrophenyl-glycoside derivatives at 1.0 mmol (mM) in the medium containing 10% fetal bovine serum to detect sugar chain elongation. However, when p-nitrophenyl-beta-N-acetylglucosamine (beta-GlcNAc-PNP) was added, the medium changed color to yellow and the cells were dead. To explain this finding, the cells were incubated with 1.0 mM each of beta-GlcNAc-PNP and 4-methylumbelliferyl-beta-N-acetylglucosamine, then the number of living cells was measured in a time course. In beta-GlcNAc-PNP, the living cells were decreased at 24 hours. The cells were survived with N-acetylglucosamine, whereas in the presence of p-nitrophenol (PNP) the living cells were decreased. It was suggested that PNP released from beta-GlcNAc-PNP induced the cell death. Activity of beta-D-N-acetylglucosaminidase was detected in fetal bovine serum. It was shown that PNP induced the cell death in time-and-dose dependent manner. Genomic DNA from COLO 201 analyzed by agarose gel electrophoresis was fragmentated. PNP analogues were tested for toxicity, and the results suggested that the phenolic OH-group linked to benzene ring and nitro-group linked to the structure in para-form (PNP) was the most effective.

[New study on the history of anesthesiology (8)--Etymological consideration on a Japanese word "Masui"]

The author briefly describes etymology of a Japanese word "Masui" ([symbol: see text]) and discusses why this word has not been correctly understood by lay people as well as Japanese anesthesiologists. The word "Masui" was coined by Seikei Sugita in 1850 when he translated Dutch edition of Schelesinger's monograph on ether anesthesia into Japanese. Therefore the word is not of Chinese origin and has subsequently been exported to China and the countries of Korean peninsula. Although half a century has elapsed since the first Department of Anesthesiology was established at the Tokyo University Faculty of Medicine, social acceptance for our specialty has not adequately and widely been achieved. The author thinks that one of the causes for this inadequate acceptance is that the correct Japanese words of "Masuika-gaku" and "Masuika-i" for Anesthesiology and Anesthesiologists were not coined and the incorrect words as "Masuigaku" and "Masui-i" have been used. Not a small number of Japanese anesthesiologists still employ the words "Masuigaku" and "Masui-i" without any special reasons.

Increased noradrenaline release from rat preoptic area during and after sevoflurane and isoflurane anesthesia

PURPOSE

To study the effects of sevoflurane and isoflurane on noradrenaline release from the rat preoptic area (POA).

METHOD

Sixteen male Wistar rats were studied. A microdialysis probe with a 2 mm long semipermeable membrane was implanted in the POA. Dialysates were collected at intervals often minutes. After obtaining five control samples for 50 min, 30 min inhalation of 3% sevoflurane or 1.8% isoflurane was performed. After cessation of the inhalation, five more samples were obtained for 50 min as recovery phase. Noradrenaline (NA) concentration in the dialysates was measured by high pressure liquid chromatography with an electrochemical detector.

RESULTS

Both sevoflurane and isoflurane caused marked increases in NA release from the rat POA (sevoflurane 233% at 20 min, isoflurane 357% at ten minutes after the start of inhalation). The marked NA releases were also observed during the emergence from sevoflurane and isoflurane anesthesia (sevoflurane 269% at 20 min, isoflurane 368% at ten minutes in the recovery phase).

CONCLUSION

This study suggests that enhanced release of NA in the POA during sevoflurane and isoflurane may explain the excitatory phase observed during the peri-anesthetic period with these agents.

Can initial distribution volume of glucose predict hypovolemic hypotension after radical surgery for esophageal cancer?

We recently reported that the initial distribution volume of glucose (IDVG) reliably measures the central extracellular fluid volume in the presence or absence of fluid gain or loss. We examined which variables, including IDVG, can predict subsequent hypovolemic hypotension produced by the continuous shift of the extracellular fluid from the central to the peripheral compartment early after radical surgery for esophageal cancer. IDVG and plasma volume were calculated after measuring cardiac index (CI), central venous pressure, and pulmonary artery wedge pressure immediately after admission to the intensive care unit. Intraoperative fluid balance and urine volume were also recorded. Postoperative hypovolemic hypotension was clinically defined as systolic blood pressure < 80 mm Hg responsive to IV fluid administration. Either IDVG < 105 mL/kg or CI < 3.4 L. min(-1). m(-2) was associated with subsequent hypovolemic hypotension (P = 0.002 for the former and P = 0.00 03 for the latter), while remaining variables were not. IDVG and CI were well correlated (r = 0.8 7, n = 25, P = 0.0001). Our results suggest that IDVG can help predict the subsequent hypovolemic hypotension early after radical surgery for esophageal cancer.

IMPLICATIONS

Routine cardiovascular variables immediately after major surgery cannot predict the subsequent hypovolemic hypotension produced by the shift of the extracellular fluid. Glucose dilution using glucose 5 g and a one-compartment model can predict it simply and rapidly.

Bronchoconstrictive and relaxant effects of lidocaine on the airway in dogs

OBJECTIVE

Intravenous lidocaine commonly is used to treat ventricular arrhythmias and to attenuate reflex airway constriction and intracranial pressure elevation during airway manipulation in intensive care units. There is much controversy as to the actions of lidocaine on the airway, so the aim of this study was to compare, in detail, the actions of lidocaine with those of bupivacaine and procaine on airway caliber and the associated changes in plasma catecholamine concentrations in the dog.

DESIGN

Prospective, randomized, controlled experimental in vivo and in vitro study.

SETTING

A university research laboratory.

SUBJECTS

Mongrel dogs.

INTERVENTIONS

In the first experiment, we evaluated the effects of intravenous local anesthetics--lidocaine 0-10 mg/kg (n = 7), bupivacaine 0-2.5 mg/kg (n = 7), or procaine 0-20 mg/kg (n = 7)--on basal airway tone. In second experiment, histamine (10 microg/kg + 500 microg x kg(-1) x hr(-1), n = 6), serotonin (10 microg/kg + 500 microg x kg(-1) x hr(-1), n = 7), and methacholine (0.5 microg/kg + 300 microg x kg(-1) x hr(-1), n = 7) were infused to determine the effects of lidocaine (0-10 mg/kg) on agonist-induced bronchoconstriction. In addition, the actions of lidocaine on vagal nerve stimulation were examined (n = 7).

MEASUREMENTS AND MAIN RESULTS

Bronchial cross-sectional area at the third bronchial bifurcation of dogs was monitored continuously through a fiberoptic bronchoscope. In the first experiment, all local anesthetics produced a dose-dependent decrease in basal bronchial cross-sectional area. In the second experiment, lidocaine significantly potentiated histamine and serotonin-induced bronchoconstriction. In contrast, lidocaine antagonized methacholine- and vagal nerve stimulation-induced bronchoconstriction.

CONCLUSION

We have clearly demonstrated that lidocaine may produce direct bronchoconstriction and worsen some agonist-induced bronchoconstriction, but it prevents reflex airway constriction. Therefore, we suggest that this agent be used with caution in asthmatics.

[New studies on the history of anesthesiology--(7). What anesthetics were given to soldiers of the fifth regiment rescued from death march on Mount Hakkoda?]

Two hundred and ten soldiers belonging to the fifth regiment of the Japanese Imperial Army started their march on Mount Hakkoda in the early morning of January 23rd, 1902. In the afternoon, they unfortunately met with a bad weather of violent gale, heavy snowfall and biting coldness to lose their way to proceed to a small village Tashiro. In the following several days, many soldiers were frozen to death and only seventeen were rescued. They were brought to the Aomori Military Hospital for admission. Among them the First Lieutenant Kuraishi and two officers were almost free from frost bite but the Major Yamaguchi died next day and a soldier died two days after his admission without any surgical treatment. The remaining eleven underwent amputation of their frostbitten extremities under general anesthesia by open drop method with a mixture of chloroform and ether, because chloroform anesthesia per se was considered much more injurious than ether to patients with poor physical status. The Military Hospital announced that the Major Yamaguchi had died due to sudden cardiac arrest, but a lay view that he had committed suicide with his gun has widely prevailed, particularly since Jiro Nitta, a novelist, referred to it in his novel "Death March on Mount Hakkoda" in 1971. According to newly discovered manuscripts written by a military surgeon Ki-ichi Murakami who served in the rescue services, both hands of the Major Yamaguchi were heavily frostbitten and his fingers were strongly flexed unable to move the trigger of his gun. Considering situations including the dates of Sadae Nakahara's visit to Aomori who was a military surgeon of the Yamagata Military Hospital, the mysterious content of a telegram to Gentaro Kodama, the War Minister, from the General Shobun Tachimi, the 8th division commander and the sudden closure of the Hospital on February 2nd, when the Major Yamaguchi died, there is a possibility that high concentrations of chloroform vapour might have been compulsorily administered to the Major Yamaguchi to cause him cardiac arrest, which the executive members of the Japanese Imperial Army would have secretly expected.

Use of olprinone, a phosphodiesterase III inhibitor, in an asthmatic patient

Phosphodiesterase (PDE) III exists in airway smooth muscles. In addition, PDEIII inhibitors have been suggested to relax airway smooth muscle by increasing intracellular cAMP concentrations. We report a successful use of olprinone, a PDEIII inhibitor, for treatment of an asthmatic attack. A 15-year-old male patient treated with oral theophylline 400 mg x d(-1) was anesthetized with propofol, fentanyl and ketamine for knee joint surgery. Immediately after tracheal intubation, an asthma attack occurred with peak airway pressure (Paw)>40 cmH2O. Thus, propofol 20 mg was additionally given to increase anesthetic depth, and Paw gradually decreased to 30 cmH2O. In addition, we started monitoring bronchial cross-sectional area using a superfine fiberoptic bronchoscopic method previously reported. However, as Paw did not further decrease for 30 min, olprinone was intravenously infused (10 microg x kg(-1) x 10 min(-1) + 0.3 microg x kg(-1) x min(-1), total 5 mg). Olprinone infusion rapidly decreased peak Paw from 30 cmH2O to 24 cmH2O and increased bronchial cross-sectional area by 50%. These findings suggest that olprinone produced bronchodilation.

Spasmolytic effect of magnesium sulfate on serotonin-induced pulmonary hypertension and bronchoconstriction in dogs

BACKGROUND

Magnesium (Mg2+) has relaxant effects on histamine-induced bronchoconstriction. In addition, Mg2+ has been reported to reduce vascular smooth muscle tone and be clinically useful for treatment of persistent pulmonary hypertension of the newborn. In this study, we evaluated the relaxant effect of Mg2+ on serotonin (5HT)-induced bronchoconstriction and pulmonary hypertension.

METHODS

Seven mongrel dogs were anesthetized with pentobarbital (30 mg x kg(-1) + 2 mg x kg(-1) x h(-1)) and paralyzed by pancuronium (0.2 mg x kg(-1) x h(-1)). Bronchoconstriction and pulmonary hypertension were elicited with 5HT (10 microg x kg(-1) + 1 mg x kg(-1) x h(-1)). Airway caliber was evaluated by changes in bronchial cross-sectional area (BCA) of the 3rd bronchial bifurcation measured by a fiberoptic bronchoscope method as previously reported. Pulmonary hypertension was assessed by changes in pulmonary vascular resistance (PVR). The BCA and PVR were expressed as per cent of the basal level. Thirty minutes after start of 5HT infusion, magnesium sulfate (MgSO4): 0 (saline), 1, 10, 100 and 1000 micromol x kg(-1) was given i.v.. Arterial blood was also collected to measure plasma level of Mg2+ and catecholamines.

RESULTS

5HT increased %PVR to 163+/-25% and decreased % BCA by 39.2+/-4.5%. Plasma level of Mg2+ following MgSO4 1000 micromol x kg(-1) i.v. exceeded its toxic level. The ED50s of MgSO4 (dose producing 50% relaxation of maximal constriction) was 47.8 micromol x kg(-1) and 1.09 mmol x kg(-1) for pulmonary hypertension and bronchoconstriction, respectively. The ratio of %PVR to %SVR was about 1.0 after MgSO4 0-100 micromol x kg(-1) i.v., although the ratio significantly increased after 1000 micromol x kg(-1) i.v..

CONCLUSION

In dogs, 5HT-induced pulmonary hypertension but not bronchoconstriction was significantly reduced by an iv bolus of MgSO4, resulting in a plasma concentration within the assumed therapeutic level.

Allelic loss mapping and physical delineation of a region harboring a thymic lymphoma suppressor gene on mouse chromosome 16

Our previous mapping of allelic loss in gamma-ray induced thymic lymphomas in F(1) hybrid and backcross mice between BALB/c and MSM strains identified three regions with high frequencies of allelic loss which probably harbor a tumor suppressor gene. One region, Tlsr7, exists near the D16 Mit122 locus on chromosome 16. This study has further localized Tlsr7 by constructing a physical map and scanning a total of 587 thymic lymphomas. The map consists of 13 overlapping BAC clones and isolation of BAC-derived polymorphic probes leads to fine mapping of allelic losses. Eleven lymphomas show informative breakpoints of allelic loss regions relative to the flanking markers on the map. Pulsed-field gel electrophoresis of NotI digests of the clones shows that the commonly lost region is localized within an approximately 300 kb interval near D16Mit192. This map is invaluable to facilitate the identification of genes in the Tlsr7 region.

Haemodynamic comparison of propofol-fentanyl anaesthesia with midazolam-fentanyl anaesthesia in CABG patients without preoperative heart failure

This study was designed to compare prebypass haemodynamics under total intravenous anaesthesia (TIVA) using midazolam-fentanyl (group M) and propofol-fentanyl (group P) combinations. Sixteen adult patients undergoing CABG were studied with patients in group M and P (n = 8 each) given intravenous midazolam 0.1 mg.kg-1.h-1 and propofol 4 mg.kg-1.h-1 with fentanyl 25 micrograms.kg-1 until sternotomy, respectively. Following induction of anaesthesia, cardiac index and heart rate decreased significantly (30% and 20% in both groups, p < 0.05) these variables returned to baseline on completion of sternotomy. In addition, in group P mean arterial pressure decreased significantly (about 15%) following induction and there were no ischaemic signs. Overall for MAP there was no significant difference between the two groups. LVSWI and RVSWI were reduced by around 25% in both groups. Only the change in LVSWI reached statistical significance (p < 0.05). This reduction may have exert a caridioprotectant action by decreasing myocardial oxygen consumption. We conclude that both TIVA techniques represent an acceptable anaesthetic regimen for use in cardiac anaesthesia.

[Combination of acute normovolemic hemodilution technique with preoperative autologous blood donation prevented allogeneic blood transfusion against 4000 g surgical blood loss in a patient undergoing left partial nephrectomy]

A 41-year-old male patient with well-controlled hypertension underwent a partial nephrectomy under total intravenous anesthesia with propofol, fentanyl and ketamine. To avoid allogeneic blood transfusion, preoperative autologous blood donation (400 g) a week before the surgery and acute normovolemic hemodilution (800 g) after induction of anesthesia were performed. As surgical blood loss was more than 4000 g, blood hemoglobin (Hb) level decreased to 6.4 g.dl-1. However, as intraoperative hemodynamics was relatively stable with no ischemic changes in ECG and arterial blood gas analysis did not show metabolic acidosis, autologous blood transfusion was withheld till hemostasis had been done. After returning the autologous blood, Hb increased to 9.4 g.dl-1. On the 2nd postoperative day, Hb decreased to 7.6 g.dl-1. As the patient's vital signs did not show any severe complications, blood transfusion was not performed. Then, the Hb level increased gradually to 13.9 g.dl-1, 3 month later without allogenic blood transfusion. In addition, any postoperative complications by low Hb level were not recognized so far. This case suggests that combination of autologous transfusion techniques may be effective to avoid allogeneic blood transfusion even against massive hemorrhage. However, to avoid disadvantage of these technique, we should always evaluate preoperative patient conditions.

Comparison of relaxant effects of propofol on methacholine-induced bronchoconstriction in dogs with and without vagotomy

Propofol has been suggested to have in vivo airway relaxant effects, although the mechanism is still unclear. In this study, we determined whether propofol could antagonize methacholine-induced bronchoconstriction and determined whether vagotomy modifies this relaxant effect. Fourteen mongrel dogs anaesthetized with pentobarbital and pancuronium were assigned to a control group (n=7) and a vagotomy group (n=7). The trachea was intubated with a special endotracheal tube that had a second lumen for insertion of the bronchoscope. Bronchial cross-sectional area, which was monitored continuously through the bronchoscope, was measured with image analysis software. Bronchoconstriction was elicited with methacholine (0.5 microg kg(-1) + 5.0 microg kg(-1) min(-1)) until the end of the experiment. Thirty minutes after the start of methacholine infusion, propofol 0, 0.2, 2.0 and 20 mg kg(-1) was administered. Changes in bronchial cross-sectional area were expressed as percentages of the basal area. Plasma concentrations of propofol and catecholamine were measured by high-performance liquid chromatography. Maximal inhibition (bronchoconstriction = 0%, baseline = 100%) and IC50 (concentration producing 50% inhibition of maximal effect) produced by propofol was obtained from each concentration-response curve using a curve-fitting program. Methacholine decreased bronchial cross-sectional area to 49.3% (95% confidence interval 38.5-60.1%) and 45.3% (34.8-55.7%) of the baseline value. Propofol 20 mg kg(-1) significantly reversed this effect: bronchial cross-sectional area was reduced to 77.8% (66.2-89.6%) and 75.9% (64.0-87.9) in the control and vagotomy groups respectively. The two groups did not differ significantly in the maximal inhibitory effect of propofol [control group, 61.1% (46.3-75.9%), vagotomy group, 64.2% (40.1-88.3%)] or pIC50 [control group 5.03 (4.55-5.51), vagotomy group 4.86 (4.49-5.24)]. Therefore, the relaxant effects of propofol on methacholine-induced bronchoconstriction may not be mediated centrally. Propofol may relax airway smooth muscles directly or through the peripheral vagal pathway.

[An immediately post-operative death of a patient undergoing right external carotid artery-posterior cerebral artery bypass]

We experienced an immediately post-operative death due to rupture of a giant basilar aneurysm four hours after right external carotid artery-posterior cerebral artery bypass surgery. As we had had preanesthetic discussions with neurosurgeons repeatedly, they did not seek for a cause of the death on our anesthetic management. However, in general, not few surgeons believe that many postsurgical complications may be mainly due to anesthetic management but not to surgery as they believe that their surgical procedures are always faultless. Therefore, we should have a wealth of anesthetic knowledge to respond to any surgeon's questions regarding anesthetic management and to precisely explain a causal relation between postsurgical complications and anesthesia. In addition, we should have frequent discussions with surgeons on postsurgical management in sick patients. These may reduce misapprehensions of surgeons, patients and their family for anesthesia.

[Marked bradycardia during anesthetic induction treated with temporary cardiac pacing in a patient with latent sick sinus syndrome]

A 59 year-old woman with latent sick sinus syndrome was scheduled to undergo ophthalmic surgery including phacoemulsification and aspiration, vitrectomy, photocoagulation and intraocular lens under general anesthesia. Preoperative ECG showed sinus rhythms of 77 bpm without bradycardia or a sinus pause. Total intravenous anesthesia with propofol, fentanyl, ketamine and vecuronium was employed for the induction of anesthesia immediately followed by severe bradycardia with a rate of 36-40 bpm including sinus arrest and atrio/nodal escaped beats. Intravenous atropine was ineffective to restore the heart rate and then urgent temporary pacing was successfully applied to overcome bradycardia. The patient recovered uneventfully from anesthesia. She complained of being dizzy and faint with prominent bradycardia due to sick sinus syndrome three months after the surgery. Therefore she underwent permanent cardiac pacemaker implantation successfully. Temporary pacing is mandatory when anesthesia is given to surgical patients with latent sick sinus syndrome.

Bradykinin-induced inositol 1,4,5-triphosphate in neonatal rat cardiomyocytes is activated by endotoxin

We studied the effect of endotoxin on bradykinin-induced inositol 1,4,5-triphosphate (IP3) production and the relationship between IP3 and phospholipase A2 or thromboxane A2. When exposed with 0.1, 1.0, and 10 microg ml(-1) lipopolysaccharide (LPS) for short-term (60 min), 100 nmol L(-1) bradykinin-induced IP3 production was stimulated in a dose-dependent manner from 569.2+/-42.4 in absence of LPS to 714.3+/-52.8, 804.5+/-42.6, and 894.1+/-62.6 pmol mg protein(-1). Treatment of 100 micromol L(-1) ACA (a phospholipase A2 inhibitor) and 10 micromol L(-1) BM13.177 (a thromboxane A2 inhibitor) significantly decreased bradykinin-induced IP3 production and LPS (1.0 microg mL(-1)) modulation of bradykinin-induced IP3 formation from 804.5+/-42.6 to 217.4+/-12.7 and 208.6+/-17.1 pmol mg protein(-1), respectively. LPS modulation of bradykinin-induced IP3 production was significantly blocked by 1 micromol L(-1) TMB-8 (an intracellular Ca2+ antagonist) from 804.5+/-42.6 to 507.8+/-33.4 pmol mg protein(-1). LPS modulation of bradykinin-induced IP3 production was significantly inhibited from 804.5+/-42.6 to 397.4+/-30.3 pmol mg protein(-1) by treatment of 10 micromol L(-1) indomethacin. In conclusion, short-term administration of LPS stimulates bradykinin-induced IP3 formation through activation of phospholipase A2 and thromboxane A2 and the stimulation is associated with an elevation of intracellular Ca2+.

A comparison of the spasmolytic effects of olprinone and aminophylline on serotonin-induced pulmonary hypertension and bronchoconstriction with or without beta-blockade in dogs

In the present study in dogs, we compared with aminophylline the spasmolytic effects of olprinone, a novel phosphodiesterase 3 inhibitor, on serotonin-induced pulmonary hypertension (PH) and bronchoconstriction. Mongrel dogs were anesthetized with pentobarbital. PH and bronchoconstriction were induced with serotonin: 10 microg/kg + 1 mg x kg(-1) x h(-1), and assessed as % changes in pulmonary vascular resistance and bronchial cross-sectional area (basal = 100%). Initially, the relaxant effects of olprinone (n = 8: 0-1000 microg/kg) and aminophylline (n = 8: 0-100 mg/kg) were compared. Pulmonary vascular resistance and bronchial cross-sectional area were assessed before and 30 min after serotonin infusion began and 5 min after each dose of olprinone or aminophylline. We then determined whether propranolol (0.4 mg/kg) reversed the relaxation induced by olprinone (1000 microg/kg, n = 6) or aminophylline (100 mg/kg, n = 6) compared with saline (n = 6 each). Olprinone and aminophylline dose-dependently attenuated both PH and bronchoconstriction (olprinone > aminophylline: -logED(50)[mean] for PH and bronchoconstriction 5.37+/- 0.35[4.24 microg/kg] vs. 1.60+/-0.23[25.4 mg/kg] and 4.06+/-0.12[87.8 microg/kg] vs. 1.51+/-0.21[30.6 mg/kg], respectively). In addition, olprinone produced more potent pulmonary vasodilation than bronchodilation while aminophylline was equipotent. In addition, there was a significant increase in plasma catecholamines after olprinone (> or =100 microg/kg) and aminophylline (> or =10 mg/kg). With the exception of aminophylline-induced bronchodilation, propranolol did not reverse any of the other effects measured. Therefore, the spasmolytic effects of olprinone are independent of plasma catecholamines, while the bronchodilating effect of aminophylline may partially involve increased levels of circulating catecholamines.

Inhibitory effects of intravenous anaesthetic agents on K+-evoked norepinephrine and dopamine release from rat striatal slices: possible involvement of P/Q-type voltage-sensitive Ca2+ channels

The role of the voltage-sensitive Ca2+ channel (VSCC) as a target for anaesthetic action remains controversial. In this study we characterized the VSCC subtypes involved in K+-evoked norepinephrine and dopamine release from rat striatal slices and used this model system to examine the effects of a range of i.v. anaesthetics on release. Nifedipine (L-channel-selective), omega-conotoxin GVI(A) (N-channel-selective), omega-agatoxin IV(A) (P-channel-selective), omega-conotoxin MVIIc (P/Q-channel-selective) and Cd2+ (non-selective), along with alphaxalone, propofol and ketamine, were used in various combinations. Omega-Agatoxin IV(A), omega-conotoxin MVIIc and Cd2+ fully (100%) inhibited norepinephrine and dopamine release. Clinically achievable concentrations of alphaxalone inhibited norepinephrine and dopamine release, with concentrations producing 25 and 50% inhibition (IC25 and IC50) of the maximum of 2.1 and 7.8 microM respectively for norepinephrine and 2.9 and 7.2 microM for dopamine. The effects of propofol were observed at the top of the clinical range and those of ketamine exceeded this range. In addition, IC50 values for alphaxalone in the presence and absence of nifedipine and omega-conotoxin GVI(A) did not differ from the control. Our data suggest that clinically achievable concentrations of alphaxalone and propofol inhibit norepinephrine and dopamine release, which is mediated predominantly through P/Q-type VSCCs, suggesting a role for these channels in anaesthetic action.

Intrathecal methylprednisolone for intractable postherpetic neuralgia

BACKGROUND

There is no effective treatment for intractable postherpetic neuralgia. Because there is evidence that postherpetic neuralgia has an inflammatory component, we assessed treatment with intrathecally administered methylprednisolone to reduce pain in patients with this disorder.

METHODS

We enrolled 277 patients who had had intractable postherpetic neuralgia for at least one year, 270 of whom were followed for two years. The patients were randomly assigned to receive intrathecal methylprednisolone and lidocaine (3 ml of 3 percent lidocaine with 60 mg of methylprednisolone acetate, 89 patients), lidocaine alone (3 ml of 3 percent lidocaine, 91 patients), or no treatment (90 patients) once per week for up to four weeks. Each weekly dose was injected into the lumbar intrathecal space. Pain was evaluated before randomization, at the end of the treatment period, and then four weeks, one year, and two years later. Samples of cerebrospinal fluid were obtained for measurement of interleukin-8 before and at the end of the treatment period.

RESULTS

There was minimal change in the degree of pain in the lidocaine-only and control groups during and after the treatment period. In the methylprednisolone-lidocaine group, the intensity and area of pain decreased, and the use of the nonsteroidal antiinflammatory drug diclofenac declined by more than 70 percent four weeks after the end of treatment. No complications related to intrathecal methylprednisolone were observed. Before treatment, the concentrations of interleukin-8 in the cerebrospinal fluid were inversely related to the duration of neuralgia in all the patients (r=-0.49, P<0.001). In the patients who received methylprednisolone, interleukin-8 concentrations decreased by 50 percent, and this decrease correlated with the duration of neuralgia and with the extent of global pain relief (P<0.001 for both comparisons).

CONCLUSIONS

The results of this trial indicate that the intrathecal administration of methylprednisolone is an effective treatment for postherpetic neuralgia.

Halothane and sevoflurane decrease norepinephrine-stimulated glucose transport in neonatal cardiomyocyte

Catecholamine regulates myocardial glucose use. However, the effect of inhaled anesthetics on myocardial glucose transport stimulated by catecholamine is unclear. We studied the effect of halothane and sevoflurane on uptake of 2-deoxyglucose stimulated by norepinephrine in neonatal cardiomyocytes and the mechanism that modulates glucose transport. We studied the effects of halothane and sevoflurane on norepinephrine (NE)-stimulated glucose uptake and the effects of halothane and sevoflurane on glucose uptake stimulated by W7 (a calcium releasing agent), phorbol 12 myristate-13-acetate (a protein kinase C agonist), and LiCl. Sevoflurane decreased NE-stimulated glucose uptake from 63.7 +/- 7.0 to 41.2 +/- 3.7 pmol h(-1) mg protein(-1), and halothane also attenuated NE-stimulated glucose uptake to 37.8 +/- 5.7 pmol h(-1) mg protein(-1). W7 at 10 micromol/L increased glucose uptake from 16.4 +/- 1.4 to 41.2 +/- 3. 4 pmol h(-1) mg protein(-1). The stimulation was inhibited in the presence of 0.8 mmol/L sevoflurane and 0.58 mmol/L halothane to 23.9 +/- 3.7 and 25.6 +/- 3.6 pmol h(-1) mg protein(-1), respectively. Halothane and sevoflurane did not significantly affect the glucose uptake stimulated by 1 nmol/L insulin, 10 micromol/L PMA, or 10 mmol/L LiCl. We conclude that halothane and sevoflurane decrease NE-stimulated glucose uptake through decrease in intracellular calcium in cardiomyocytes.

IMPLICATIONS

The effect of inhaled anesthetics on myocardial glucose uptake during administration of catecholamine is unclear. The myocardial glucose uptake is stimulated not only by catecholamine, but also by insulin, protein kinase C, and increase of intracellular calcium. We examined the effects of halothane and sevoflurane on glucose uptake.

[New study on the history of anesthesiology--(5) and (6). Reevaluation of surgical achievements by Tokumei Takamine]

A half century has passed since K. Higaon-na, a historian from Okinawa, first reported that in 1689 Tokumei Takamine (1653-1738) had performed successfully a hare-lip operation under general anesthesia with mafutsu-san for a royal grandchild Sho-eki of the Ryukyu Dynasty in the Ruykuys, now known as Okinawa. As Higaon-na obtruded his opinion above mentioned without any substantial proof on the public, and many medical historians as well as historians have followed him thereafter. No historical documents are available concerning surgical achievements by Tokumei Takamine to clarify them in detail but it clearly says in the genealogy of the Takamines that Kou Kaiyu ([symbol: see text]) taught his ancestral prescription and surgical technique of hare-lip operation to Tokumei Takamine on his repeated solicitation when they stayed in Fu-chou. Takamine made two scrolls describing the secret prescription and surgical method of hare-lip, and presented them to a magistrate Genzaimon Murao and his physician Doh-yo Isashiki in 1690. In 1986, a scroll has been found in Sendai city of Kagoshima prefecture, which was transcribed by two physicians named Antei Kore-eda and Encho Nagai at Kagoshima in 1754. No information is available about biographies of these two physicians. A careful study of this scroll has revealed that it bears the prescription of an ointment including ten remedies to dress the incision and surgical method of hare-lip. Accordingly it is clearly proven by this newly discovered scroll that Tokumei Takamine did not administer any general anesthetics when he performed surgical operations for hare-lip on several occasions.

Increased plasma vasopressin and atrial natriuretic peptide in chronic schizophrenic patients during abdominal surgery

Chronic schizophrenic patients are reported to develop imbalanced water homeostasis by the pathological secretion of vasopressin and aldosterone. We measured plasma vasopressin, aldosterone and atrial natriuretic peptide in schizophrenic patients to elucidate the role of these hormones during a perioperative period. Eighteen schizophrenic patients with chronic antipsychotic drugs over 10 years and 22 as a control group who underwent elective lower abdominal surgery were the subjects of this study. In the schizophrenic patients, plasma aldosterone secretion was significantly inhibited, while plasma vasopressin and atrial natriuretic peptide were significantly increased during surgery. A good relationship (r = 0.69, p < 0.01) between plasma atrial natriuretic peptide and plasma osmolality was obtained 60 min after skin incision, but not before the induction of anesthesia. The findings suggest that chronic schizophrenic patients may develop an abnormal secretion of vasopressin, aldosterone and atrial natriuretic peptide during anesthesia.

Current perception thresholds of epileptic patients treated with valproate

We investigated the current perception threshold (CPT) of epileptic patients treated with valproate. The CPTs at frequencies of 5 Hz, 250 Hz and 2000 Hz in the control group of patients were 198.9 +/- 15.8, 62.0 +/- 18.9 and 35.3 +/- 15.8, respectively. The CPTs at 5 Hz, 250 Hz and 2000 Hz in the epileptic group of patients were 350.6 +/- 61.3, 338.6 +/- 64.3 and 193.2 +/- 21.1, respectively. The CPTs at 5 Hz, 250 Hz and 2000 Hz in the epileptic group were significantly higher than those of the control group. We measured the CPTs for 6 months after the administration of valproate in three patients with traumatic epilepsy. Their CPTs were higher than that of the epileptic group. The CPTs at 5 Hz, 250 Hz and 2000 Hz reached a maximum 4 weeks after the administration of valproate for two of these patients and in 6 weeks for the other patient. When the administration of valproate to a patient was stopped, CPTs decreased.

The initial distribution volume of glucose rather than indocyanine green derived plasma volume is correlated with cardiac output following major surgery

OBJECTIVES

To determine whether the initial distribution volume of glucose (IDVG) rather than plasma volume or blood volume is correlated better with cardiac output during the 4 days following major surgery.

DESIGN AND SETTING

Prospective clinical investigation in the general intensive care unit of a university hospital.

PATIENTS AND METHODS

31 consecutive patients who underwent radical surgery for esophageal carcinoma were enrolled. Continuous thermodilution cardiac output monitor was placed in the operating room. Indocyanine green (ICG; 25 mg) and glucose (5 g) were administered simultaneously to calculate IDVG and plasma volume determined using the ICG dilution method. Blood volume was also calculated from plasma volume ICG and hematocrit. Those volumes were measured on admission to the ICU and daily on the first 3 postoperative days. The relationships between each volume and cardiac index (CI), and between routine clinical variables and CI were evaluated.

RESULTS

IDVG had a linear correlation with CI in the early postoperative days (r = 0.71, n = 124, p < 0.000001). Measurements of neither the plasma volume nor the blood volume yielded a better correlation with CI than did IDVG (r = 0.45, n = 124, p < 0.000001, and r = 0.23, n = 124, p < 0.01, respectively). No correlation was found between pulmonary artery wedge pressure and CI or between central venous pressure and CI.

CONCLUSIONS

Our results indicate that IDVG rather than intravascular volume is correlated with cardiac output. We suggest that IDVG has potential as an alternative indicator of cardiac preload following major surgery.

Barbiturates inhibit K(+)-evoked noradrenaline and dopamine release from rat striatal slices--involvement of voltage sensitive Ca(2+) channels

The cellular target site(s) for anaesthetic action remain unclear. In rat striatal slices we have previously demonstrated that K(+)-evoked noradrenaline (NA) and dopamine (DA) release is mediated predominantly via P/Q-type voltage sensitive Ca(2+) channels (VSCC). Using this model of Ca(2+) dependent transmitter release we have evaluated the effects of anaesthetic and non-anaesthetic barbiturates. Rat brain striatal slices were incubated in the absence and presence of barbiturate for 10 min at 37 degrees C. The slices were then incubated for 6 min with 40 mM KCl. All anaesthetic barbiturates produced a concentration-dependent inhibition of K(+)-evoked NA and DA release. Non-anaesthetic barbiturate, barbituric acid was ineffective. The pIC(50) for NA and DA release (thiopental: 4.90+/-0.13 and 5.00+/-0.10, pentobarbital: 4.39+/-0.07 and 4.43+/-0.14, phenobarbital: 3.85+/-0.08 and 3.59+/-0.10, respectively) correlated with lipid solubility (NA: r(2)=0.999, DA: r(2)=0.987). We therefore suggest that barbiturates inhibit catecholamine release via an interaction with P/Q VSCC further implicating this channel in anaesthetic action.

Current perception thresholds and postoperative pain in schizophrenic patients

BACKGROUND AND OBJECTIVES

Schizophrenic patients may have less sensitivity to pain; however, pain insensitivity in schizophrenia has not been adequately evaluated. We investigated current perception threshold (CPT) and postoperative pain intensity in patients with long-standing and treated schizophrenia and control patients.

METHODS

We measured CPTs for 2,000 Hz, 250 Hz, and 5 Hz and postoperative pain intensity using a visual analogue scale (VAS) in 50 chronic schizophrenic patients who were on chronic phenothiazine derivatives (> 10 years) and for 25 control patients.

RESULTS

CPTs for 2,000 Hz, 250 Hz, and 5 Hz in schizophrenic patients were 334.2 +/- 112.2, 303.9 +/- 117.1, and 165.0 +/- 72.3, respectively. CPTs for 2,000 Hz, 250 Hz, and 5 Hz in schizophrenic patients were significantly higher than those of control patients. VAS pain scores of schizophrenic patients were 4.0 +/- 1.7 at 2 hours post-operatively and 3.8 +/- 1.5 at 5 hours postoperatively, which were significantly (P < .05) lower than those (5.0 +/- 1.6 and 5.1 +/- 1.9) of the control group.

CONCLUSIONS

Chronic schizophrenic patients have increased current perception threshold and lower VAS pain scores in postoperative pain compared with control patients.

Use of an EEG-bispectral closed-loop delivery system for administering propofol

Closed-loop control of propofol delivery was instituted in three patients who received a propofol infusion as part of: (Case 1) general "balanced" anesthesia, (Case 2) total intravenous anesthesia, and (Case 3) monitored anesthesia care. The bispectral index was the input variable used in a proportioned, integral and differential controller to determine the infusion rate of propofol required to maintain a stable level of hypnosis (Cases 1 and 2) or sedation (Case 3). This feedback control system provided intraoperative hemodynamic stability and a prompt recovery from the sedative-hypnotic effects of propofol.

[New studies on the history of anesthesiology--a new study on Seishu Hanaoka's "Nyugan Ckiken Roku" (a surgical experience with breast cancer)]

Among Japanese physicians before the Edo era, Seishu Hanaoka is the most well known even in foreign countries as well as in Japan. His detailed biography is described in a monograph by Shuzo Kure published in 1923 which has been the most important book for the study of Seishu Hanaoka. Hanaoka had worked very hard in various fields as surgeons, educator, poet and community developer. However, his best noted activity was his devotion to the development of oral general anesthetic "Mafutsu-San" or "Tsusen-San". He was the first to succeed in the excision of breast cancer in a 60 year old woman named Kan Aiya under general anesthesia with this agent on Oct 13th, 1804. The details of the case have been known to us, as the manuscript on the case which is believed to be by the hand of Hanaoka is extant in the Tenri Library, Tenri University and the whole manuscripts have been printed in Kure's monograph. For the past twenty years, I have studied carefully the microfilmed manuscript and the printed sentences appeared in Kure's book to find several serious bibliographical errors and dubious points between them. They are as follows. 1) There is no definite proof that the manuscript was transcribed by Seishu Hanaoka himself. This was originally proposed by Shuzo Kure without any rational reasons. 2) There are seven fundamental and unbelievable errors of incorrect use of Chinese characters in the manuscript. These basic errors can not be committed by Hanaoka considering that he was an excellent poet. For these errors Shuzo Kure falsified them to be printed in his book. He even altered Chinese characters in one of the photographs of the manuscript in his book. 3) Shuzo Kure did not exhibit this manuscript at the exhibition on the occasion of 150 anniversary of Seishu Hanaoka's death in Tokyo, supposedly to avoid careful study by other investigators. All above mentioned findings strongly suggest us that the manuscript "Nyugan Chiken Roku" could be transcribed by one of Hanaoka's disciples and not by Hanaoka himself.

Spasmolytic effects of prostaglandin E1 on serotonin-induced bronchoconstriction and pulmonary hypertension in dogs

In this study, we simultaneously evaluated the spasmolytic effects of prostaglandin E1 (PGE1) on serotonin-induced bronchoconstriction and pulmonary hypertension. Eleven mongrel dogs (8-12 kg) anaesthetized with pentobarbital were assigned to two groups: saline (n = 4) and PGE1 (n = 7). Bronchoconstriction and pulmonary hypertension were elicited with serotonin 10 micrograms kg-1 + 1 mg kg-1 h-1 and assessed as the percentage change in bronchial cross-sectional area (BCA) measured by bronchoscopy and pulmonary vascular resistance (PVR), respectively. Thirty minutes after starting the serotonin infusion, saline or PGE1 0 (saline), 0.01, 0.1, 1.0 or 10 micrograms kg-1 i.v. was given. %BCA and %PVR (basal = 100%) were assessed before and 30 min after serotonin, and 30 and 60 min after saline (saline group) or 5 min after each dose of PGE1 (PGE1 group). In the saline group, pulmonary hypertension and bronchoconstriction were stable. In the PGE1 group, PGE1 at > or = 0.1 microgram kg-1 significantly decreased %BCA and 10 micrograms kg-1 almost fully reversed the constriction (from mean (SEM) 56.2% (4.9%) to 94.4% (3.7%)). %PVR was significantly decreased at 10 micrograms kg-1 (from 230% (24%) to 176% (11%)) only. We suggest that PGE1 may produce bronchodilation rather than pulmonary vasodilation.