Cloning and characterization of maxi K+ channel alpha-subunit in rabbit kidney

We have identified in rabbit renal cells two alternatively spliced transcripts of the alpha-subunit rbslo1 and rbslo2. Rbslo1 has a novel "in-frame" 174-bp insertion immediately after the predicted S8 transmembrane segment, whereas rbslo2 has a 104-bp deletion between S9 and S10, creating a frameshift and a premature termination codon. Amino acid identity between mouse maxi K- channel alpha-subunit (mslo) and rbslol was 99%. Two transcript sizes of 4.2 and 7.5 kb were detected in brain, kidney, stomach, testis, and lung. Rbslo is expressed in glomeruli, thin limbs of Henle's loop, medullary and cortical thick ascending limbs of Henle's loop, and cortical, outer, and inner medullary collecting ducts; however, it was rarely detected in proximal convoluted tubules. Rbslo1 is most abundant in inner medulla. Expressed in Xenopus oocytes, rbslo1 generates depolarization-activated, outwardly rectifying K+ currents. Rbslo1 expressed in Chinese hamster ovary cells could be activated by depolarization and Ca2+. These data suggest that rbslo transcripts are expressed in multiple nephron segments and that the magnitude of mRNA expression varies among different nephron segments.

Interactions between nicardipine and enflurane, isoflurane, and sevoflurane

PURPOSE

During nicardipine induced hypotension, different inhalational anaesthetics may have different effects on haemodynamic variables, sympathetic function and drug metabolism. Therefore, the haemodynamic effects and pharmacokinetics of nicardipine were studied in the presence of the three inhalation anaesthetics enflurane, isoflurane and sevoflurane.

METHODS

Thirty patients scheduled for neurosurgery were randomly assigned to one of three anaesthetic techniques: enflurane, isoflurane or sevoflurane. Nicardipine (0.017 mg.kg-1) was administered during stable anaesthesia and the following measurements made for 30 min: blood pressure, heart rate, and plasma concentration of norepinephrine, epinephrine and nicardipine.

RESULTS

With sevoflurane, plasma concentrations of nicardipine, five minutes after administration, (39.8 +/- 3.5 ng.ml-1, mean +/- SEM) were higher (P < 0.05) than in the other two groups (28.3 +/- 2.9 ng.ml-1, 32.6 +/- 4.3 ng.ml-1, enflurane and isoflurane, respectively). With isoflurane, the approximated half-life of nicardipine (14 +/- 4 min) was shorter and clearance (2.1 +/- 0.3 l.min-1) more rapid. Peak heart rates were similar in all groups but elevated rates continued longer with isoflurane (> 30 min). Nicardipine-induced reduction in blood pressure was greater with sevoflurane but low pressures persisted for longer with isoflurane. Plasma catecholamine concentrations increased with isoflurane and enflurane, but not with sevoflurane: considerably higher epinephrine concentrations were seen with isoflurane.

CONCLUSION

This study showed that the action of nicardipine is modified by different inhalational anaesthetic agents. Nicardipine has a prolonged duration of action in the presence of isoflurane and produces greater initial hypotension with sevoflurane.

Same day drainage and removal of a giant ovarian cyst

PURPOSE

An unusual case of a giant ovarian cyst was successfully anaesthetized with a combination of epidural followed by general anaesthesia. The method was chosen to avoid circulatory depression and re-expansion pulmonary oedema in removal of a giant tumour in a woman who did not understand the nature of her disease.

CLINICAL FEATURES

A 58-yr-old woman (107.6 kg, 150 cm and abdominal girth: 163.5 cm) was admitted for removal of a giant ovarian cyst. There was gross-pitting oedema of both legs and an elevated diaphragm but no pleural effusion. She did not understand the severity of her disease. It was decided to drain the cyst gradually, followed by total surgical removal on the same day. An epidural catheter was inserted at the L3-4 interspace with the patient in the left lateral position and, under epidural anaesthesia, 44.3 L fluid were drained over two hours without producing circulatory depression or pulmonary oedema. General anaesthesia was induced, with the patient in the supine position, by slow injection of 10 mg midazolam, 100 micrograms fentanyl and inhalation of nitrous oxide 50% in oxygen, and maintained with adding epidural block using lidocaine 1.5% and bupivacaine 0.5%, and sevoflurane 0.4 to 0.8%. During surgery, the volume of infused fluid was carefully controlled with central venous pressure monitoring. Ulinastatin, a protease inhibitor, was infused to prevent pulmonary oedema. No circulatory depression nor pulmonary oedema occurred perioperatively.

CONCLUSION

For the removal of a giant ovarian cyst, slow drainage over two hours under epidural anaesthesia may safely precede later removal of the cyst on the same day under general anaesthesia.

Haemodynamic and catecholamine changes during rapid sevoflurane induction with tidal volume breathing

PURPOSE

To compare haemodynamic and plasma catecholamine changes with rapid (three minute) inhalational anaesthesia induction with tidal volume breathing of sevoflurane 7%, conventional (seven minute) slow inhalation induction with increasing sevoflurane concentration up to 5%, and induction with thiamylal i.v.

METHODS

Twenty-four patients were randomly divided into three groups of eight. In Group A, anaesthesia was induced with tidal volume breathing of sevoflurane 7% (inspiratory concentration) and nitrous oxide 50% in oxygen (total flow; 6 l.min-1) for three minutes: Group B received conventional slow induction for seven minutes and increasing sevoflurane concentration by 0.5% every two or three breaths up to 5% with nitrous oxide 50% in oxygen: and Group C received 5 mg.kg-1 thiamylal with an inhalation of 100% oxygen. Blood pressure, heart rate, rate pressure product, and plasma concentrations of epinephrine and norepinephrine were measured.

RESULTS

There were no changes in blood pressure before or after intubation in Group A (sevoflurane 7%) whereas both were increased in patients in Group C (thiamylal). Changes in heart rate and rate pressure product were not different for the two inhalation groups. Plasma epinephrine concentrations decreased in all the three groups. Norepinephrine concentrations were increased before intubation in both inhalation groups but not in the thiamylal group.

CONCLUSION

Rapid induction of anaesthesia with sevoflurane 7% and tidal volume breathing for three minutes induced less haemodynamic changes than the other methods studied and has no inhibitory effect on sympathetic activity.

[Effects of cardiac output on PETCO2 and PaCO2 during combined inhalational-epidural anesthesia]

We investigated the effects of cardiac output on PETCO2 in anesthetized patients. We studied 8 adult patients undergoing long-lasting lower abdominal surgery. Anesthesia was maintained with epidural combined with inhalational anesthesia. The minute ventilation volume was kept constant at 10 ml.kg-1 x 10 cycles.min-1. PETCO2, PaCO2, and cardiac index, (CI) by thermodilution method were measured simultaneously. PaCO2 was corrected for body temperature for comparison with PETCO2. Approximate value of alveolar dead space to tidal volume ratio was calculated as VD/ VTalv = (PaCO2-PETCO2)/PaCO2. The measurements were repeated every 10 to 20 minutes under the steady body temperature. One hundred and six sets of data were obtained from these patients. PETCO2 as well as PaCO2 correlated positively with CI, while VD/VTalv did not correlate with CI. PETCO2 correlated positively with PaCO2, while it did not correlate with VD/VTa1v. When examined in individual patients, PETCO2 correlated positively with CI in 7 patients. PaCO2 correlated positively with CI in 6 patients, while VD/VTa1v correlated negatively with CI only in 2 patients, in whom CI showed a large fluctuation. PaCO2 correlated positively with PETCO2 in 8 patient, while VD/VTa1v correlated negatively with PETCO2 only in 1 patient. By multiple regression analysis, VD/VTa1v change accounted for only 20.0 +/- 15.3% of PETCO2 change, while PACO2 or PaCO2 change accounted for 79.3 +/- 16.7%. Decreased CI was associated with a decrease in oxygen uptake (VO2), and PaCO2 correlated positively with VO2. Decreased CI was also associated with an increase in VA/Q, and PaCO2 correlated negatively with VA/Q. Thus, PETCO2 decreased with decreasing cardiac output. A decrease in PACO2 explained the decrease in PETCO2 better than an increase in VD/VT did. Decreased cardiac output caused hypocapnia through decreased CO2 production and/or increased ventilation to perfusion ratio i.e. relative hyperventilation.

Laminin alpha2 chain-null mutant mice by targeted disruption of the Lama2 gene: a new model of merosin (laminin 2)-deficient congenital muscular dystrophy

Using the gene targeting technique, we have generated a new mouse model of congenital muscular dystrophy (CMD), a null mutant for the laminin alpha2 chain. These homozygous mice, designated dy3Kldy3K, are characterized by growth retardation and severe muscular dystrophic symptoms and die by 5 weeks of age. Light microscopy revealed that muscle fiber degeneration in these mice begins no later than postnatal day 9. In degenerating muscles, considerable amounts of TUNEL positive nuclei were detected as well as DNA laddering, suggesting increased apoptotic cell death was involved in the process of muscle fiber degeneration.

[Clinical use of midazolam]

Midazolam is widely used in anesthesia. This paper shows characteristics of midazolam and how to use midazolam in clinical anesthesia. As a premedication, midazolam should be injected i. m. 15 min before entering an operating room in a dose of 0.04 mg.kg-1 to 0.08 mg.kg-1 according to the patient's age. For anesthesia induction, midazolam should be used together with barbiturate or propofol to take advantage of synergistic effects. Continuous infusion of midazolam in total intravenous anesthesia with fentanyl results in hemodynamic stability and good postoperative analgesia. During spinal or epidural anesthesia, i.v. midazolam of 0.05 mg.kg-1 has anti-anxietic and sedative effects. Midazolam inhibits awakening during cardiopulmonary bypass and it has little cardiodepressant effect. In aged, hepatic damaged or renal damaged patients, the effects of midazolam are slightly increased. Therefore, lower doses may be required in such patients. In conclusion, midazolam is usable in premedication, induction, maintenance in general anesthesia and in sedation in local anesthesia.

Wells' syndrome: a pathogenic role for circulating CD4+CD7- T cells expressing interleukin-5 mRNA

Wells' syndrome, or eosinophilic cellulitis, is a rare dermatosis characterized histologically by a dermal infiltrate of eosinophils, lymphocytes and histiocytes between collagen bundles and amorphous or granular eosinophilic deposits on collagen, constituting flame figures. We report a 54-year-old woman with eosinophilic cellulitis whose peripheral blood showed a marked eosinophilia and a high proportion of CD4+CD7- cells before treatment. Reverse transcriptase-polymerase chain reaction revealed that CD4+CD7- cells, but neither CD4+CD7+ nor CD4-CD8+ cells, in the circulating mononuclear cells expressed mRNA for interleukin (IL)-5, the major cytokine involved in eosinophilia. The proportion of CD4+CD7- cells decreased, and expression of mRNA for IL-5 disappeared in the peripheral blood, when the disease was treated by the administration of intravenous recombinant interferon-gamma. These findings suggest that circulating CD4+CD7- T cells play a pivotal role in the pathogenesis of eosinophilic cellulitis by producing IL-5.

Beneficial effects of the prone position on the incidence of barotrauma in oleic acid-induced lung injury under continuous positive pressure ventilation

BACKGROUND

Factors that contribute to ventilator-induced barotrauma are not well defined. This study investigates the effects of posture on ventilator-induced barotrauma, as well as arterial oxygenation.

METHODS

Twelve dogs with oleic acid lung injury, lying in the prone position (n = 6) and right lateral position (n = 6), were mechanically ventilated with continuous positive pressure ventilation for 24 hours. The incidence of pneumothorax and arterial oxygenation were investigated in each position.

RESULTS

All animals lying in the lateral position developed pneumothorax in the nondependent thorax, while only one animal in the prone position developed pneumothorax in the left thorax (P < 0.05). Postmortem examination revealed that in the lateral group, the nondependent lung consisted of large areas of emphysematous regions and neutrophil infiltration regions, while the dependent lung was composed of extensive atelectasis and neutrophil infiltration. Lung ruptures occurred in the nondependent lung at the regions of either emphysematous change or severe neutrophil infiltration. In the prone group, in contrast, both lungs were inflated fairly homogeneously with only small areas of atelectatic and emphysematous changes. In the dog in whom pneumothorax developed, lung ruptures were limited to the regions of severe neutrophil infiltration in the left lung. No animal in either group had a peak airway pressure more than 20 cmH2O. The peak airway pressures were 17.5 +/- 1.3 cmH2O in the lateral group and 16.6 +/- 2.1 cmH2O in the prone group (P > 0.05). Tidal volume was comparable between the lateral group (13 +/- 2 ml/kg) and the prone group (12 +/- 1 ml/kg) before pneumothorax occurred (P > 0.05). Arterial oxygenation was much better in the prone group than in the lateral group during the experiment (P < 0.05).

CONCLUSION

It was concluded that in lung injury dogs, the prone position has beneficial effects on the incidence of ventilator-induced barotrauma and arterial oxygenation when compared with the lateral position. Ventilator-induced barotrauma may occur at lower airway pressure.

[The effect of low-dose prostaglandin E1 on serum and urinary fluoride concentrations in patients anesthetized with sevoflurane]

We investigated the effects of low-dose prostaglandin E1 (PGE1) on serum and urinary concentrations of inorganic fluoride in 39 adult patients undergoing upper abdominal surgery. Anesthesia was maintained with a combination of N2O-O2-sevoflurane and thoracic epidural anesthesia. Twenty-two patients received infusion of PGE1 at a rate of 0.02 micrograms.kg-1.min-1 throughout surgery. Seventeen patients served as control by not receiving PGE1. Serum inorganic fluoride concentrations (FB) were determined before the induction of anesthesia and 0, 2 and 24 hours after the end of anesthesia. Urinary inorganic fluoride concentrations (FU) were determined before the induction of anesthesia, and 0, 24 and 48 hours after the end of anesthesia. These was no difference between PGE1 group and control group in anesthetic dose (MAC hours) of sevoflurane. In both groups, FB peaked at the end of anesthesia. In PGE1 group, UB peaked at the end of anesthesia, while in control group, it peaked 24 hours after anesthesia. There were differences between groups neither in FB nor in FU throughout the study period. The relationships between anesthetic dose and fluoride concentrations, however, differed significantly between the groups. In control group FB values of 0, 2 and 24 hours after anesthesia correlated positively with MAC hours, respectively, while in PGE1 group they did not. Similarly in control group, FU values of 24 and 48 hours after anesthesia correlated positively with MAC hours, respectively, while in PGE1 group, they did not. Thus in patients receiving high-dose sevoflurane, FB and FU tended to be lower in PGE1 group than in control group. In contrast, in PGE1 group, urinary excretion of fluoride during surgery correlated positively with MAC hours, while in control group, it did not. Urinary fluoride excretion during surgery was significantly greater in PGE1 group than in control group. These results suggested that PGE1 might prevent elevation of serum and urinary fluoride concentrations in patients receiving high-dose sevoflurane. This effect might result from enhanced urinary excretion of fluoride with PGE1.

Functional expression and germline transmission of a human chromosome fragment in chimaeric mice

Human chromosomes or chromosome fragments derived from normal fibroblasts were introduced into mouse embryonic stem (ES) cells via microcell-mediated chromosome transfer (MMCT) and viable chimaeric mice were produced from them. Transferred chromosomes were stably retained, and human genes, including immunoglobulin (Ig) kappa, heavy, lambda genes, were expressed in proper tissue-specific manner in adult chimaeric tissues. In the case of a human chromosome (hChr.) 2-derived fragment, it was found to be transmitted to the offspring through the germline. Our study demonstrates that MMCT allows for introduction of very large amounts of foreign genetic material into mice. This novel procedure will facilitate the functional analyses of human genomes in vivo.

Role of purinergic receptors in chloride secretion in Caco-2 cells

Purinergic receptors play an important role in regulating Cl- secretion in epithelial cells. To explore further the role of these receptors in the intestine, we utilized the human intestinal epithelial cell line, Caco-2, grown on permeable membrane supports and assayed for Cl- secretion by measuring the short-circuit current (Isc). Stimulation of Isc by extracellular nucleotides could be detected by day 4 and increased by day 10 postseeding. The magnitude of stimulation of Isc at 10 microM in cells at day 10 was UTP > ATP > UDP > > 2-methylthioadenosine 5'-triphosphate (2-MeS-ATP) = ADP on the apical side and UTP = 2-MeS-ATP = ATP > ADP > > UDP on the basolateral side. Cross-desensitization studies suggested that two different receptors are expressed in the apical membrane, a P2U purinoceptor and a uridine nucleotide receptor. Two different receptors are also expressed in the basolateral membrane, a P2U receptor and another that reacts with both 2-MeS-ATP and ADP. This latter receptor has an unusual pharmacological profile, with a reactivity for 2-MeS-ATP > ADP but not for ATP. Responses to purinergic receptor agonists were inhibited by pretreatment with 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid-acetoxymethyl ester, thapsigargin, or quinine. Thus we suggest that an increase in intracellular Ca2+ and subsequent opening of Ca(2+)-activated K+ channel play a role in increasing driving force for Cl- to exit across the apical membrane. The role of the cystic fibrosis transmembrane conductance regulator as a Cl- exit pathway on the apical membrane was also established.

[The effect of low-dose prostaglandin E1 on intra- and post-operative liver function]

We investigated the effects of low-dose prostaglandin E1 (PGE1) on intra- and post-operative liver function in 109 adult patients undergoing upper abdominal surgery. Patients were divided into 2 groups; Control group (n = 42) and PGE1 group (n = 67). In PGE1 group, PGE1 was infused throughout surgery at a rate of 0.02 microgram kg-1 min-1. In both groups, anesthesia was maintained with a combination of inhalational and thoracic epidural anesthesia. Epidural anesthesia was maintained with 1.5% lidocaine infused epidurally at a constant rate (8 +/- 2 ml.hr-1). The continuous epidural infusion of lidocaine was initiated before surgery and discontinued at the end of surgery. Preoperative and postoperative liver function was evaluated with blood chemistry examination. Intraoperative liver function was evaluated in 84 patients (33 in control group and 51 in PGE1 group) by measuring plasma lidocaine concentration. Plasma lidocaine concentration was determined 1 and 3 hours after the initiation of lidocaine infusion and 0 and 2 hours after its termination. There were no differences between the groups in doses and infusion rates of lidocaine. In both groups, lidocaine concentration increased progressively as infusion was continued. Lidocaine concentration was significantly lower in PGE1 group than in control group at the end of the infusion. In 22 patients in control group and 35 in PGE1 group who received high-dose lidocaine (> 8 mg.kg-1), lidocaine concentration remained significantly lower in PGE1 group than in control group throughout the infusion period. The difference in lidocaine concentrations between the groups increased progressively as infusion was continued, though the doses and the infusion rates of lidocaine were not different between the groups. Postoperative liver function did not differ between the groups. Because removal of lidocaine from blood to liver parallels hepatic blood flow, the lower plasma lidocaine concentration in PGE1 group indicated that hepatic blood flow was higher and liver function was better-maintained with PGE1 during anesthesia and surgery. Low dose PGE1 thus improved intraoperative liver function during upper abdominal surgery.

Subacute and chronic prurigo effectively treated with recombination interferon-gamma: implications for participation of Th2 cells in the pathogenesis of prurigo

Subacute and chronic prurigo is notoriously resistant to usual therapies. Four of five patients with a subacute or chronic form of prurigo responded well to daily intravenous injections of recombinant interferon-gamma (rIFN-gamma) (0.25-2 x 10(6) Japan Reference Unit (JRU; 1 JRU roughly corresponds to 4 NIH units) daily, for 10-14 days). In one patient examined, the dermal portion of lesional skin before the treatment contained considerable amounts of mRNA for interleukin (IL)-4, IL-5, and IL-10, indicative of infiltration of Th2 cells. Furthermore, the administration of rIFN-gamma selectively down-regulated mRNA for Th2 cytokines, IL-4 and IL-10 in peripheral blood mononuclear cells. These findings suggest that Th2 cells play a pathogenic role in these types of prurigo and that rIFN-gamma exerts its efficacy by inhibiting Th2 cells. Our pilot study suggests that the systemic administration of rIFN-gamma is a therapeutic alternative for the treatment of recalcitrant prurigo.

[The effect of low-dose prostaglandin E1 on intra- and post-operative renal function]

We investigated the effects of low-dose prostaglandin E1 (PGE1) on intra- and post-operative renal function in 109 adult patients undergoing upper abdominal surgery. Anesthesia was maintained with a combination of thoracic epidural combined with inhalational anesthesia. Sixty-seven patients received PGE1 at a rate of 0.2 microgram.kg-1.min-1 throughout surgery. Forty-two patients, who did not receive PGE1, served as control. Pre- and post-operative renal function was evaluated with serum levels of BUN and creatinine (Cr), while intra-operative renal function was evaluated mainly with urine output and urine flow rate during anesthesia. Urinary Na excretion and creatinine clearance (Ccr) were determined during surgery in limited cases. Urine output and urine flow rate during anesthesia were greater in PGE1 group than in control group, whereas infusion volumes and infusion rates were not different between the groups. In PGE1 group, urine flow rate was greater during surgery than before surgery, while in control group, it was unchanged. Na excretion during anesthesia was also greater in PGE1 group than in control group. In control group, Na excretion and Ccr were smaller during surgery than before surgery, while in PGE1 group, they were unchanged. Postoperative serum BUN and creatinine levels were not different between the groups. Decreased Na excretion and decreased Ccr in control group indicated that renal function was depressed during surgery, whereas unchanged Ccr, unchanged Na excretion and increased urine flow rate in PGE1 group indicated that renal function was well-maintained during surgery with PGE1. Low-dose PGE1 thus prevented depression of renal function during surgical anesthesia.

[Low preoperative PaO2 in patients with ovarian and endometrial cancer]

We investigated preoperative PaO2 and changes of PaO2/FIO2 (P/F) during the operation in 40 patients with gynecologic malignancies (ovarian cancer (O group) = 14 cases, endometrial cancer (E group) = 14 cases, cervical cancer (C group) = 12 cases). Preoperative chest X-ray and respiratory function test of our patients were within normal ranges (% VC > or = 80, % FEV 1.0 > or = 70). There were no differences among 3 groups in age, height, weight, % VC, or % FEV 1.0. Preoperative PaO2 values in the O group and E group were significantly lower than the normal value (100--age/4). Preoperative PaO2 and P/F values in the O group were significantly lower in comparison with those in the C group. We suggest, therefore, that it is necessary to measure preoperative PaO2 in patients with ovarian and endometrial cancer.

[Successful treatment of intraoperative myocardial ischemia with nicorandil]

We report five patients who developed intraoperative myocardial ischemia but were treated successfully with nicorandil. Case 1; An 84 year-old male underwent emergent laparotomy and ileolysis under inhalational plus thoracic epidural anesthesia. During his emergence from anesthesia, arterial pressure and heart rate increased abruptly due to excitement, leading to ST-T depression on V5 lead. Bradycardia and hypotension developed subsequently. Immediately after i.v. injections of nicorandil 4 mg and atropine 0.3 mg, ST-T change and hemodynamics improved dramatically. Case 2; A 67 year-old male underwent esophagectomy under inhalational plus thoracic epidural anesthesia. Following the completion of surgery, elevation of ST-T developed suddenly on lead II, though hemodynamics were not compromised. ST-T elevation disappeared immediately after nicorandil 6 mg and continuous infusion of nitroglycerin (TNG) was initiated. Case 3; A 71 year-old female underwent aortic valve replacement under high-dose fentanyl anesthesia. Shortly after starting cardiopulmonary bypass (CPB), ST-T segment on leads II and V5 was elevated suddenly. This was accompanied by severe pulmonary hypertension suggestive of severe left ventricular failure. Shortly after nicorandil 4 mg via a pulmonary artery (PA) catheter, ST-T segment returned to the baseline and pulmonary arterial pressure was normalized. Case 4; A 61 year-old male underwent coronary revascularization under high-dose fentanyl anesthesia. During weaning from CPB, elevation of ST-T segment occurred on leads II and V5. ST change improved, responding to nicorandil 6 mg en bolus via a PA catheter. Case 5; A 67 year-old male underwent coronary revascularization under high-dose fentanyl anesthesia. He was unable to be weaned from CPB for several hours because of frequent and repeated attacks of ventricular tachycardia and ventricular fibrillation. The arrhythmia did not respond to various kinds of treatments including intra-aortic balloon pumping and continuous infusions of inotropes, anti-arrhythmic drugs and anti-anginal drugs. In spite of repeated intracoronary injections of TNG, graft flow to the left anterior descending branch remained low at 40 ml.min-1. After an intracoronary injection of nicorandil 1 mg, however, blood flow increased to 100 ml.min-1, resulting in a marked reduction in frequency of ventricular arrhythmia. The patient came off bypass successfully. In each case, intraoperative myocardial ischemia was treated successfully with nicorandil. Neither hypotension nor arrhythmia resulted from its bolus injection. Nicorandil might be a useful therapeutic tool for myocardial ischemia during anesthesia.

[The effect of low-rose prostaglandin E1 on circulation, respiration and body temperature during surgical anesthesia]

We investigated the effects of low-dose prostaglandin E1 (PGE1) on circulation, respiration, and body temperature during surgical anesthesia. We studied 109 adult patients undergoing upper abdominal operations under thoracic epidural combined with inhalational anesthesia. Patients were divided into 2 groups; Control group (n = 42) and PGE1 group (n = 67). In PGE1 group, PGE1 infusion was started at the rate of 0.02 microgram.kg-1.min-1 before the induction of anesthesia and was terminated at the end of surgery. There were no differences between the groups in demographic, anesthetic and surgical characteristics. After treatment with PGE1, arterial pressure decreased slightly but significantly, resulting in lower arterial pressure in PGE1 group than in control group before the induction of anesthesia. After the induction of anesthesia, however, arterial pressure decreased significantly in both groups, and the differences in arterial pressure between the groups were not observed any more during surgery. Heart rate was not different between the groups throughout the study period. Intraoperative urine output was greater in PGE1 group than in control group. PaO2/FIO2 ratio was not different between the groups both before and during anesthesia. Rectal temperature remained slightly but significantly lower in PGE1 group throughout surgery. Rectal-to-palm temperature gradient tended to be smaller in PGE1 group 1 hour after the induction of anesthesia. Low-dose PGE1 reduced arterial pressure. However, the difference in arterial pressure between the groups was so small that the difference disappeared during surgery. Meanwhile, low-dose PGE1 increased urine output, suggesting that renal blood flow was better-maintained with PGE1. In spite of several investigations reporting an unfavorable effect of PGE1 on PaO2, low dose PGE1 did not affect PaO2 in this study. Finally low-dose PGE1 reduced core temperature, though slightly, probably through redistribution of the body heat.

[Combined spinal and epidural anesthesia for laparotomy in a geriatric patient with severe obstructive lung disease]

Asthma and heavy smoking are the risk factors for postoperative respiratory distress, especially after general anesthesia. We experienced a case of sigmoidectomy in a geriatric patient with severe obstructive lung disease accompanied by asthma and a long history of smoking. The patient was a 70 year old man with 1 second volume of less than 0.6 l, because of asthma and long smoking history of 40 pieces of cigarettes a day for 50 years. We considered that general anesthesia with tracheal intubation might worsen the respiratory state after surgery and chose combined spinal and epidural anesthesia. He received sigmoidectomy under spinal anesthesia with 0.3% dibucaine 2.4 ml combined with epidural anesthesia. As the level of analgesia went up to Th4, the patient complained of dyspnea and he discharged a plenty of sputum. Without any special treatment his dyspnea disappeared spontaneously. During and after the surgery, no exacerbation occurred in his respiratory state. It is suggested that spinal anesthesia combined with epidural anesthesia is useful for a patient with severe obstructive lung disease.

Vagal and sympathetic denervation in the development of oleic acid-induced pulmonary edema

This study investigates the effects of autonomic denervation on extravascular lung water, pulmonary hemodynamics, the filtration coefficient of pulmonary vasculature and oxygenation in the development of pulmonary edema. Thirty seven dogs were divided into seven groups. No experimental treatment was conducted in group Nc (n = 4, sham operation) or group Nv (n = 6, bilateral vagotomy) during a 3 h observation period. In the following groups, oleic acid (0.06 ml/kg) was injected into a central vein to induce pulmonary edema: group OAc (n = 6, intact innervation); group OAv (n = 6, bilateral vagotomy); group OAa (n = 6, alpha-blockade by phentolamine); group OAs (n = 6, alpha- and beta-blockade by sympathectomy); and group OAvs (n = 3, vagosympathectomy). The results showed that in the dogs with normal lungs, bilateral vagotomy per se did not cause lung injury during 3 h of observation. However, in oleic acid pulmonary edema, vagotomy significantly deteriorated pulmonary edema by increasing pulmonary intravascular pressures; Alpha- or alpha- and beta- sympathetic inhibition deteriorated pulmonary edema by increasing pulmonary microvascular permeability. The severity of oleic acid-induced pulmonary edema was same in the dogs with vagosympathectomy as in the dogs with intact innervation. These results suggest the inhibition of vagal or sympathetic innervation will aggravate pulmonary edema in the dog.

[Aspiration pneumonia during the endotracheal intubation on the occasion of bladder perforation by TUR]

We report on two cases of aspiration pneumonia which developed during the endotracheal intubation after bladder perforation during TUR. The first case was a 79 y.o. male, who underwent TUR-P and lithotripsy under spinal and epidural anesthesia. The second case was a 69 y.o. male, who had undergone TUR-Bt under nitrous oxide-oxygen-enflurane anesthesia. General anesthesia was selected to perform an laparotomy when the diagnosis was made. They vomited a considerable amount of gastric content just after giving the drugs for induction. The chest X-rays revealed signs of aspiration pneumonia. These X-ray findings improved in a week using antibiotic therapy. Although TUR is performed as scheduled, vomiting may occur in the case of unexpected bladder perforation, which can cause aspiration pneumonia. In such emergency, we should insert a nasal tube before induction, press the cricoid (crush induction), or intubate with the patient awake.

Cerebrovascular CO2 reactivity in elderly and younger adult patients during sevoflurane anaesthesia

PURPOSE

General anaesthetic agents and aging affect cerebrovascular CO2 reactivity (CCO2R). The purpose of this study was to investigate the effect of aging on CCO2R in patients during sevoflurane anaesthesia.

METHODS

Twenty-four patients were divided into two groups of 12 according to age; 20-40 yr and 50-70 yr. Anaesthesia was induced with 5 mg.kg-1 thiopentone and maintained with sevoflurane 1.0 to 1.5% (end-tidal) and nitrous oxide 66% in oxygen to maintain anaesthesia. End-tidal CO2 tension (PETCO2) was altered from 20 to 50 mmHg in 5 mmHg steps by changing the respiratory rate. Middle cerebral blood flow velocity (CBFV) and pulsatility index (PI) were measured by transcranial Doppler (TCD) at each step change in PETCO2. The CCO2R was calculated as the change of CBFV per mmHg at each 5 mmHg interval.

RESULTS

In each group, there were no changes in blood pressure, heart rate, end-tidal sevoflurane concentration, or PI as the PETCO2 was increased from 20 to 50 mmHg. The CCO2R at PETCO2 of 35 to 50 mmHg in the younger group (0.80 +/- 0.27 (SD) cm.sec-1.mmHg-1) was larger than that in the elderly group (0.31 +/- 0.16 cm.sec-1.mmHg-1) (P < 0.01).

CONCLUSION

It is concluded that, during sevoflurane anaesthesia, CCO2R is well preserved, and that the CCO2R at PETCO2 of 35 to 50 mmHg in the 20 to 40 yr age group is greater than that in the 50 to 70 yr age group.

[A simple, lightweight device for measurement of hemoglobin; the HemoCue Blood Hemoglobin Test]

In some situations such as a sudden bleeding during surgery, rapid testing of blood hemoglobin concentration is necessary. The HemoCue Blood Hemoglobin Test uses a lightweight photometer, which is easily movable anywhere. The HemoCue needs only 10 microliters of blood and it takes only about 45 seconds to produce the result. Therefore, the device might be useful in the operating suite and the emergency unit. To evaluate the accuracy of the HemoCue, we compared the blood hemoglobin concentrations measured by the HemoCue with those measured by the ABL 300. A positive correlation was found between the variables by the HemoCue (Y) and those by the ABL 300 (X); Y = 0.944X - 0.208, r = 0.97, P < 0.001. It is concluded that the HemoCue is a reliable device for measurement of blood hemoglobin concentration.