[Anesthesia for emergency surgery in a patient with Shy-Drager syndrome]

A 53-year-old man with Shy-Drager syndrome underwent emergency surgery for the resection of the larynx under general anesthesia. Anesthesia was induced with fentanyl 0.1 mg and thiopental 100 mg, and endotracheal intubation was facilitated with vecuronium 8 mg. The onset of action of vecuronium was very slow. Anesthesia was maintained with about 1% of sevoflurane, with nitrous oxide 3 l.min-1 in oxygen 3 l.min-1. Norepinephrine was effective for hypotension while dopamine was not. He was extubated on the first postoperative day without any complications. The effects of vecuronium, norepinephrine, and dopamine might be changed in the patient with Shy-Drager syndrome.

Co-assembly of polycystin-1 and -2 produces unique cation-permeable currents

The human kidney is composed of roughly 1.2-million renal tubules that must maintain their tubular structure to function properly. In autosomal dominant polycystic kidney disease (ADPKD) cysts develop from renal tubules and enlarge independently, in a process that ultimately causes renal failure in 50% of affected individuals. Mutations in either PKD1 or PKD2 are associated with ADPKD but the function of these genes is unknown. PKD1 is thought to encode a membrane protein, polycystin-1, involved in cell-cell or cell-matrix interactions, whereas the PKD2 gene product, polycystin-2, is thought to be a channel protein. Here we show that polycystin-1 and -2 interact to produce new calcium-permeable non-selective cation currents. Neither polycystin-1 nor -2 alone is capable of producing currents. Moreover, disease-associated mutant forms of either polycystin protein that are incapable of heterodimerization do not result in new channel activity. We also show that polycystin-2 is localized in the cell in the absence of polycystin-1, but is translocated to the plasma membrane in its presence. Thus, polycystin-1 and -2 co-assemble at the plasma membrane to produce a new channel and to regulate renal tubular morphology and function.

Adenosine A1 receptor blockade reverses dysmotility induced by ischemia-reperfusion in rat colon

This study was designed to assess whether adenosine A1 receptor antagonists [(R)-1-[(E)-3-(2-phenylpyrazolo[1,5-a]pyridin-3-yl) acryloyl]-piperidin-2-yl acetic acid (FK352) and 8-cyclopentyl-1,3-dipropylxanthine (DPCPX)] reverse dysmotility induced by ischemia-reperfusion in the rat colon. The gene of adenosine A1 receptor was expressed in the colon. Clamping (30 min) of the colonic marginal vessels was followed by reperfusion, and the propulsive colonic motility was evaluated. Propulsion was significantly slowed by ischemia-reperfusion, while FK352 and DPCPX abolished this delay. In contrast, the non-selective adenosine receptor antagonist, 8-phenyltheophylline, failed to affect the dysmotility. Thus, adenosine A1 receptor antagonists have potent therapeutic potential against ischemia-reperfusion-induced dysmotility in the colon.

Continuous nicardipine infusion to control blood pressure after evacuation of acute cerebral hemorrhage

PURPOSE

To explore the long-term effects of the calcium antagonist, nicardipine, on cerebral hemodynamics in patients with acute cerebral hemorrhage, we investigated the effects of nicardipine infusion on intracranial pressure (ICP), middle cerebral arterial blood flow velocity (Vmca) , and computed tomographical (CT) findings of bleeding and edema.

METHODS

Twenty-two patients with acute cerebral hemorrhage were infused with nicardipine for > 72 hr to decrease blood pressure. Blood pressure, heart rate, conscious level, Vmca, pulsatility index (PI, using transcranial Doppler), ICP, cerebral perfusion pressure (CPP) and platelet counts were monitored. CT examination was also performed to detect the changes of bleeding (hematoma) and/or brain edema.

RESULTS

Blood pressure decreased (20 to 30% from control, P < 0.05) without any changes in heart rate. Platelet count did not change neither did Vmca and PI change on either the intact or injured side. The ICP decreased 24 hr after the end of infusion from 30 +/- 12 mmHg to 20 +/- 9 mmHg (P = 0.036) but was still higher than normal. The CPP decreased at 24 hr (75 +/- 14 mmHg, P = 0.026) and 72 hr (73 +/- 15 mmHg, P = 0.024) from the baseline (99 +/- 17 mmHg). Conscious level improved but not significantly and CT findings did not show any exacerbation in bleeding or edema.

CONCLUSION

In patients with acute cerebral hemorrhage, nicardipine infusion to decrease blood pressure by 20 to 30% had no effect on Vmca, ICP, cerebral bleeding and edema, but decreased CPP.

Nicardipine did not activate renin-angiotensin-aldosterone system during isoflurane or sevoflurane anesthesia

PURPOSE

To investigate the changes of renin-angiotensin-aldosterone system by nicardipine administration during isoflurane or sevoflurane anesthesia.

METHODS

Twenty patients aged 40 to 70 yr for elective neurosurgery were studied. Anesthesia was induced with thiopental, midazolam and fentanyl and was maintained with nitrous oxide in oxygen and isoflurane or sevoflurane. When blood pressure was constant, 0.017 mg x kg(-1) nicardipine was administered as a bolus. Blood pressure, heart rate, and plasma concentrations of nicardipine, angiotensin I and II, aldosterone and renin activity were measured for 30 min after nicardipine administration.

RESULTS

Blood pressure decreased for 30 min after nicardipine administration in both groups with lower values during sevoflurane anesthesia. Heart rate increased only in the isoflurane group. Plasma nicardipine concentrations did not differ between isoflurane and sevoflurane groups. Plasma renin activity and concentrations of angiotensin II and aldosterone did not change in either groups and there were no differences between groups. Plasma concentration of angiotensin I increased at 20 and 30 min after nicardipine administration in the isoflurane group but not in the sevoflurane group.

CONCLUSION

The activity of renin-angiotensin-aldosterone system did not increase by a single dose administration of nicardipine in isoflurane or sevoflurane anesthesia.

[Airway obstruction after general anesthesia in a patient with the first and second branchial arch syndrome]

A 20-year-old female with the first and second branchial arch syndrome underwent plastic surgery. Due to her mandibular hypoplasia and trismus, tracheal intubation was difficult even with a broncho-fiberscope. Fentanyl 100 micrograms was used for nasal intubation. Anesthesia was maintained with nitrous oxide (4 l.min-1), oxygen (2 l.min-1) and sevoflurane (0.5-3%). There were no troubles during surgery. The trachea was extubated after recovery of consciousness and spontaneous respiration. Five minutes after extubation, airway was obstructed suddenly after massive nasal bleeding. Sudden massive bleeding might have caused airway obstruction. Emergency insertion of an 18 G needle followed by Mini-trach II into the trachea through the cryothyroidal ligament improved her respiratory condition. The case suggests that preparing the instrument for the emergency cryothyroidal ligament puncture (for instance Mini-trach II) is useful for a patient with a risk of bleeding in the airway and with difficult intubation.

[Anesthetic management for MIDCAB using the target controlled infusion and the bispectral index]

We report our experience in using the target controlled infusion (TCI) of propofol combined with the bispectral index (BIS) monitoring for anesthetic management of minimally invasive direct coronary artery bypass (MIDCAB) in a 43-year-old-male patient with angina pectoris. After premedication, the patient was connected to the monitor with electrodes for BIS monitor. Then, anesthesia was induced with fentanyl and propofol using TCI technique. When blood concentration of propofol reached 4 micrograms.ml-1, the trachea was intubated. Before starting the operation, we evaluated the relationship between blood concentration of propofol and the value of BIS, and the standard maintenance concentration of propofol was set at 3 micrograms.ml-1. When the concentration of propofol was 3 micrograms.ml-1, the value of BIS was about 60. Anesthesia was maintained with nitrous oxide and oxygen and continuous infusion of propofol using TCI technique. When necessary, we gave additional injection of fentanyl and vecuronium bromide. Furthermore, diltiazem was infused continuously for cardiac rate control, as well as infusion of nicorandil, nitroglycerine for prevention of coronary artery spasms, and prostaglandin. After the operation, the patient was alert in 8 minutes and we could extubate in 12 minutes. The use of TCI combined with BIS monitoring for maintenance of anesthesia for MIDCAB is useful and safe.

Polycystin-1, the gene product of PKD1, induces resistance to apoptosis and spontaneous tubulogenesis in MDCK cells

The major form of autosomal dominant polycystic kidney disease (ADPKD) results from mutation of a gene (PKD1) of unknown function that is essential for the later stages of renal tubular differentiation. In this report, we describe a novel cell culture system for studying how PKD1 regulates this process. We show that expression of human PKD1 in MDCK cells slows their growth and protects them from programmed cell death. MDCK cells expressing PKD1 also spontaneously form branching tubules while control cells form simple cysts. Increased cell proliferation and apoptosis have been implicated in the pathogenesis of cystic diseases. Our study suggests that PKD1 may function to regulate both pathways, allowing cells to enter a differentiation pathway that results in tubule formation.

A traumatic asphyxia in a child

PURPOSE

Traumatic asphyxia in a child is rare and the pathophysiology is different from that occurring in an adult. We report a case of traumatic asphyxia in a child who recovered without specific treatment, even though chest and abdominal compression was severe.

CLINICAL FEATURES

A three-year-old boy (14.2 kg) was run over by the rear wheel of a Jeep. He was under the tire for about three minutes and then was transferred to our hospital. When he arrived, he was lethargic with Glasgow Coma Scale of E3V4M6 (coma score of 13). He was cyanotic in his face and had a tire mark from the left shoulder to the right abdomen, petechiae on the head, face, conjunctiva and chest, oral bleeding, and facial edema. Serum concentrations of liver enzymes were increased and microhematuria was detected. However, no injuries were seen in the brain, eye, chest, or abdomen. Cyanosis disappeared in a few hours. Facial and thoracic petechiae disappeared in three days and that of the conjunctiva in five days. He was discharged from hospital on the 13th day without any disturbances.

CONCLUSION

We present a three-year-old boy with traumatic asphyxia. He had no complications although he received severe thoraco-abdominal compression by a Jeep.

[General anesthesia for a patient on hemodialysis with arteriosclerosis obliterans]

A 48-year-old man with arteriosclerosis obliterans was scheduled for axillofemoral bypass. He had chronic renal failure and on hemodialysis (HD) for 22 years. On the morning of the day of surgery he received HD and two hours later anesthesia was induced with fentanyl 300 micrograms and midazolam 6 mg, and maintained with fentanyl, nitrous oxide and intermittent isoflurane. The common carotid artery was cannulated to measure arterial blood pressure because arteries in extremities were not available. Internal jugular vein at the other side of the arterial catheterization was cannulated to measure central venous pressure. Crystalloid and blood transfusion was performed to adjust hemodynamics and central venous pressure. Hemodynamics were stable during surgery and no complication occurred regarding the common carotid arterial line. The common carotid artery was useful for blood pressure monitoring in a patient whose extremities were not available. Midazolam and fentanyl could give stable hemodynamics to a patient with arteriosclerosis obliterans and chronic renal failure.

Reversible tricuspid valve obstruction during removal of renal cell carcinoma with intracardiac tumor extension

IMPLICATIONS

Transesophageal echocardiography was used to identify and guide management of reversible tricuspid valve obstruction by a tumor mass during surgical removal of a renal cell carcinoma.

[Anesthesia for a cervical myelopathy patient with tracheal stenosis]

A 71-year-old male with cervical myelopathy was scheduled for C 3-7 laminectomy. Once he had been rejected of general anesthesia in other hospital because of his tracheal stenosis. The diameter of the narrowest part of his trachea was 5 mm probably resulting from tracheostomy at 2 years of age. His cervical myelopathy seemed to be no problem for anesthesia induction because he had no problems in his neck movement and opening mouth. We evaluated his tracheal stenosis carefully using bronchofiberscopy, chest X-ray, computed tomography and pulmonary function tests. After intravenous fentanyl 100 micrograms and midazolam 2.5 mg, it was impossible to ventilate the patient. Therefore, tracheal intubation was performed immediately after lidocaine administration into the trachea. During surgery, tracheal tube dilated the narrowed portion. After surgery, the tracheal tube was removed under bronchofiberscopic observation without any problems. Tracheal stenosis was observed by chest X-ray after surgery, but he had no complaints.

The effects of epidural bupivacaine, morphine, and their combination on thermal nociception with different stimulus intensity in rats

The analgesic effect of drugs depends on the stimulus intensity as well as the potency of the drugs. We investigated the effects of stimulus intensity on antinociceptive potencies of epidural bupivacaine + morphine. Sprague-Dawley rats implanted with chronic lumbar epidural catheters were tested for paw withdrawal response to thermal stimulation after the epidural injection of bupivacaine, morphine, or bupivacaine + morphine. Two stimulation currents were used, 5.1 and 4.6 A, to provide baseline response latency of approximately 5.0 s (high intensity) and 10.0 s (low intensity), respectively. Increasing the dose of epidural morphine in a dose range that had a maximum effect on low-intensity stimulation was not effective for high-intensity stimulation. Bupivacaine, which alone had no effect, potentiated the antinociceptive effect of epidural morphine at both high- and low-intensity stimuli similarly. We concluded that bupivacaine potentiated the analgesic effect of epidural morphine at both weak and strong nociceptive stimuli similarly, whereas increasing the dose of epidural morphine was not as effective for strong nociceptive stimulation. Therefore, adding bupivacaine might be more effective than increasing the dose of epidural morphine for intense nociception.

IMPLICATIONS

When patients have severe pain even when receiving epidural morphine, adding bupivacaine might be more effective than increasing the dose of epidural morphine.

Effects of amrinone on ischaemia-reperfusion injury in cirrhotic patients undergoing hepatectomy: a comparative study with prostaglandin E1

The effects of amrinone, a selective phosphodiesterase III inhibitor, on liver ischaemia reperfusion injury have not yet been clarified. Forty-five patients with hepatocellular carcinoma who underwent partial liver resection using Pringle's manoeuvre were studied. Patients were divided into three groups: those given amrinone, those given prostaglandin E1 (PGE1) and those not treated (controls). An indocyanine green (ICG) clearance test was performed before the operation and three times during surgery: just before induction of liver ischaemia, just after liver resection and 60 min after reperfusion. Blood lactate and base excess were measured at the same times. Systolic and diastolic arterial pressure, heart rate, cardiac index and oesophageal temperature were monitored. Aminotransferase levels were recorded the day before surgery, 1 h after operation and on the first and third postoperative days. These data were compared between groups. The ICG elimination rate, lactate and base excess in the amrinone group differed significantly from those in controls during the observation period (P = 0.03, P = 0.04 and P = 0.03, respectively). The differences between the PGE1 and control groups were not significant. There were no significant differences between the groups in perioperative vital signs, cardiac index or postoperative aminotransferase. Amrinone enhanced intraoperative ICG elimination in cirrhotic patients who underwent liver resection.

Free hemoglobin concentrations in patients receiving massive blood transfusion during emergency surgery for trauma

PURPOSE

To determine free hemoglobin concentration in patients who received massive blood transfusion during emergency surgery for trauma with consideration of the storage of the transfused blood.

METHODS

Fifteen patients undergoing emergency surgery for multiple trauma and who received blood transfusion of more than 5000 mL were studied. Transfusion of the stored whole blood in citrate-phosphate glucose solution using a micropore filter was started before surgery. Serum concentrations of hemoglobin (total:THb and free:fHb) and total haptoglobin (THp) were measured until 5,000 mL of blood had been transfused. Serum free haptoglobin (fHp) concentration was calculated. The correlation between the changes in hemoglobin or haptoglobin concentrations and total storage days of the transfused blood was analyzed by a simple regression analysis.

RESULTS

Free hemoglobin was detected after 2,000 mL transfusion. The THp and fHp decreased after 1,000 mL transfusion. Total storage time (days) of transfused blood had correlated with the changes of THp (P < 0.0001) and fHp (P = 0.0027) but not with the changes of THb (P = 0.984) and fHb (P = 0.834).

CONCLUSION

After blood transfusion during surgery for trauma, serum haptoglobin concentration decreased with transfusion of > or = 1,000 mL of whole blood with mean storage time of 12.2 dy. Free hemoglobin was detected after 2,000 mL transfusion when THp decreased to 1,000 mgxL(-1). Serum haptoglobin concentrations correlated negatively with storage time (days) of transfused blood.

Serological diagnosis of idiopathic pulmonary alveolar proteinosis

Previously, we reported the specific occurrence of neutralizing autoantibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF) in the bronchoalveolar lavage fluid from 11 Japanese patients with idiopathic pulmonary alveolar proteinosis (I-PAP). The autoantibody was also detected in sera from all 5 I-PAP patients examined. To determine that the existence of the autoantibody is not limited to the Japanese patients, we examined sera from 24 I-PAP patients in five countries and showed that the autoantibody was consistently and specifically present in such patients. Thus, detection of the autoantibody in sera can be used for diagnosis of I-PAP. To establish a simple and convenient method for diagnosis of I-PAP, we developed a novel latex agglutination test using latex beads coupled with recombinant human GM-CSF. GM-CSF binding proteins isolated from the sera using the latex beads were identified as the autoantibodies of IgG(1) and IgG(2). The titer of the autoantibody determined by this test correlated with that determined by ELISA. Agglutination was positive in 300-fold diluted sera from all 24 I-PAP patients, but negative in sera from four secondary PAP patients, two congenital PAP patients, 40 patients with other lung diseases, and 38 of 40 normal subjects. These results establish that the latex agglutination test is a reliable method for serological diagnosis of I-PAP with high sensitivity (100%) and specificity (98%).

[Hoarseness after endotracheal intubation caused by submucosal hemorrage of the vocal cord and recurrent nerve palsy]

Hoarseness often follows endotracheal intubation. A 58 year old man suffered from hoarseness due to recurrent nerve palsy and submucosal hemorrhage of the right vocal cord after general anesthesia. He was scheduled for resection of chronic pyoderma of the buttocks and atheroma of the right retroauricular region. Anesthesia was induced with thiopental 300 mg and endotracheal intubation was facilitated with vecuronium 6 mg. A spiral tube with 8 mm of inner diameter (Mallinckrodt Medical) was inserted with no problems. The tube was fixed at left side of the mouth. The cuff was inflated with air but the cuff pressure was not monitored. Anesthesia was maintained with sevoflurane (1-3%) and 67% N2O in 33% O2. Respiration was controlled mechanically. The patient was turned to the prone position and his head was turned to the right. The duration of surgery was one hour and forty minutes. Extubation of the tube involved no problems. He complained of hoarseness after surgery. Right recurrent nerve palsy and submucosal hematoma were observed. Without any treatment, hematoma disappeared in 70 days and hoarseness in 183 days. These hematoma and recurrent nerve palsy might be due to the compression of the vocal cord and recurrent nerve by tracheal tube and traction of the recurrent nerve by rotation of the neck.

[Anesthetic management for neonates with congenital cystic adenomatoid malformation]

We experienced two cases of congenital cystic adenomatoid malformation (CCAM) diagnosed by prenatal ultrasonography. The first case with type I CCAM underwent the resection of the right upper lobe 8 days after birth. Postoperative course was uneventful. The second case with type III CCAM developed non-immune hydrops, severe mediastinal shift, and polyhydroamnios at 29 weeks' gestation. At 30 weeks' gestation, cesarean section was performed. Immediately after birth, the resection of lung tumor for the neonate was performed. However, the neonate died on the 1st postoperative day.

[General anesthesia for a patient with Cornelia de Lange syndrome]

Cornelia de Lange syndrome involves anomalies in cardio-vascular and musculo-skeletal systems, and mental retardation. In addition, a patient with this syndrome shows a peculiar look. A 22-year-old woman with Cornelia de Lange syndrome underwent general anesthesia twice. She has a small mouth, thin lips, a short neck, short limbs, and stiffness of the neck and some joints associated with slight mental retardation. She was scheduled for arthroscopy and then for rotational acetabular osteotomy and valgus osteotomy. The maximum distance between the upper and lower incisors was 34 mm, when she opened her mouth. Anesthesia was induced with sevoflurane increased slowly to 7.0% in oxygen 6 l.min-1 in both procedures. After the administration of 4% lidocaine 3.5 ml into the pharynx, orotracheal intubation was attempted, but was not successful. Then blind naso-tracheal intubation was performed successfully under spontaneous respiration under sevoflurane-oxygen inhalation. The induction of anesthesia with sevoflurane under spontaneous respiration was useful for blind naso-tracheal intubation in a case with difficult intubation such as in Cornelia de Lange syndrome.

[Combined intercostal nerve block and epidural anesthesia in a patient with severe aortitis syndrome]

A 74-year-old woman with aortitis syndrome was scheduled for mastectomy. Her left vertebral artery was totally occluded and left carotid arteries, left subclavia artery and bilateral common renal arteries were occluded. For anesthesia a catheter was inserted into the epidural space between T3 and T4. Lidocaine 80 mg (2%, 4 ml) was administered epidurally. Then intercostal nerve block was performed with bupivacaine 15 mg (0.5%, 3 ml) at T3 and T4 level. Local infiltration of lidocaine 50 mg (1%, 5 ml) was added. During the surgery, hemodynamics were stable and no neurological symptom was observed. Epidural anesthesia alone might be sufficient for anesthesia if higher concentration of local anesthetic was used. However, to avoid hemodynamic change, we used 1% lidocaine and added intercostal nerve block. We conclude that combined intercostal nerve block and epidural anesthesia was useful for a patient with severe aortitis syndrome in oder to monitor consciousness to detect cerebral ischemia and to avoid hemodynamic instability.

Effects of the sniffing port air makeup in gas chromatography-olfactometry

A time-intensity gas chromatography-olfactometry (GCO) apparatus was developed to study some aerodynamic parameters that may influence odor detection and intensity measurements by the subjects. The addition of humidified air at the elution place of the compounds is generally recommended for several reasons (essentially to prevent nasal mucosa dehydration and to improve chromatographic effluent carriage out of the column), but clues about these effects are yet to be published. This question is studied through two complementary experiments using synthetic solutions of 3-methyl-1-butanethiol, hexan-2-one, octanal, nonanal, furfural, citronellal, benzaldehyde, octan-1-ol, 2-phenylethyl acetate, guaiacol, 2-phenylethanol, and vanillin. This work demonstrates the need for an air makeup to increase odor detection frequency and intensity rating. With the conditions tested, a minimum makeup air flow rate of 50 L.min(-)(1) is necessary. On the contrary, humidification of the makeup is useless for the sniffers comfort and to improve the quantitative GCO results.

Peri-operative blood lactate levels in recipients of living-related liver transplantation

BACKGROUND

The role of changes in peri-operative blood lactate levels in recipients of living-related liver transplants has not yet been clarified.

METHODS

Forty-three recipients were included in this study. Blood lactate, plasma total bilirubin, aminotransferase, body temperature, and gastric mucosal PCO2 levels were measured at six time points during surgery: just before the initiation of surgery, just after dissection of the hepatic vasculature, at the end of the anhepatic phase, and 30, 60, and 120 min after reperfusion. We calculated the rate of lactate accumulation during the pre-anhepatic and anhepatic phases and the elimination rate during reperfusion (neohepatic phase), and examined the correlation between these results and the clinical findings.

RESULTS

The rate of lactate elimination during the neohepatic phase was correlated with the ratio of graft weight to standard liver volume (P<0.0001). There was also a significant correlation between the rate of lactate accumulation during the pre-anhepatic phase and the preoperative total bilirubin levels (P=0.0008).

CONCLUSIONS

Each pre-anhepatic, anhepatic, and neohepatic phase had a characteristic blood lactate profile. The graft size strongly affected lactate levels during the early neohepatic phase.