Nafamostat mesilate, a kallikrein inhibitor, prevents pain on injection with propofol

We have examined the preventative effect of nafamostat mesilate, a kallikrein inhibitor, on pain on injection with propofol in a randomized, double-blind study. A control group (n = 110) and a nafamostat (n = 103) group received 5% glucose 0.02 ml kg-1 and nafamostat 0.02 mg kg-1 diluted with 5% glucose, respectively, followed 1 min later by 1% propofol injected at a rate of 200 mg min-1. Pain scores recorded during injection of propofol were significantly less in the nafamostat than in the control group. In another 10 patients, blood concentrations of nafamostat were measured after administration of nafamostat 0.02 mg kg-1 i.v. Mean nafamostat concentration 1 min after injection was 0.1 (SD 0.05) mumol litre-1, which is sufficient to inhibit plasma kallikrein activity. We conclude that pretreatment with nafamostat 0.02 mg kg-1 significantly reduced pain on propofol injection and this effect may be caused by a reduction in kallikrein activity.

[The effect of cervical sympathectomy on the pituitary and pineal endocrine system]

It was reported previously that continuous exposure to light in male rats increased serum luteinizing hormone (LH) and bilateral cervical sympathectomy inhibited such a change. In the present report, to examine the effect of cervical sympathectomy on the pineal endocrine function, 30 male rats were assigned to five groups. The control (C) group and the light (L) group underwent sham sympathectomy as well as sham pinealectomy. The sympathectomy (S) group underwent sympathectomy and sham pinealectomy. The pinealectomy (P) group and pinealectomy-melatonine (PM) group underwent sympathectomy and pinealectomy. The C group was kept under a normal circadian rhythm for 10 days, and the other groups were kept under continuous exposure to light for the same period. The PM group received subcutaneously 10 mg.kg-1 of melatonine every day. Serum LH levels were measured 10 days following these experiments. With regard to serum LH levels, the differences among C group, L group, and S group were similar to those previously reported. It was higher in P group (2.53 +/- 0.40 ng.ml-1) than in S group (1.58 +/- 0.61 ng.ml-1), and lower in PM group (2.08 +/- 0.31 ng.ml-1) than in P group. In conclusion, it is suggested that the endocrine activity of melatonine from the pineal gland plays an important role in the appearance of the effect of cervical sympathectomy.

[Effect of positive end-expiratory pressure on respiration and hemodynamics in dogs with pulmonary edema caused by increased membrane permeability]

The effect of PEEP on the extravascular lung water, respiratory mechanics and hemodynamics were studied in dogs with oleic acid-induced pulmonary edema. The dogs were randomized into one of three groups according to PEEP of 0, 5 and 10 cmH2O, 60 minutes after oleic acid (0.1 ml.kg-1) injection. PEEP improved oxygenation accompanied by increased FRC and DLco. However, oxygen delivery decreased in association with the decreased cardiac index caused by application of PEEP. PEEP failed to decrease the extravascular lung water volume measured by double-indicator dilution technique after lung edema formation.

[The effect of nicardipine hydrochloride upon the pulmonary arterial pressure]

This study examines the effects of induced hypotension with intravenous administration of nicardipine hydrochloride (NIC) upon pulmonary arterial pressure (PAP) undergoing modified radical mastectomy with neuroleptanesthesia (NLA-group; 3 cases) and inhalation anesthesia (N2O+ isoflurane; GOI-group; 3 cases). Systolic arterial pressure was reduced and maintained at 80 mmHg. During and after induced hypotension in NLA-group, heart rate (HR), cardiac index, pulmonary arterial pressure (PAP) increased remarkably. On the other hand, systemic vascular resistance index was reduced. In GOI group, no significant changes were seen in PAP. The acceleration of the autonomic baro-reflex induced by decreased blood pressure produced by NIC may be depressed under anesthesia to initiate this difference in response of HR to NIC. The data indicate that this depressive effect of NLA on this reflex is weak, and NIC is a potent systemic vasodilator with hyperdynamic hemodynamic effects in addition to an increase in right ventricular function, and PAP was increased.

[Continuous epidural droperidol for postoperative pain]

We investigated the proper dosage of droperidol continuously infused into the epidural space. Sixty patients who received continuous epidural infusion of buprenorphine for 24 hours were divided into four groups (Group I: only buprenorphine, Group II: 1.25 mg of droperidol added to buprenorphine, Group III: 2.5 mg of droperidol added to buprenorphine, Group IV: 5 mg of droperidol added to buprenorphine). No significant difference was observed in prevention of nausea and vomiting among 4 groups. But in group II, III and IV, there was a tendency of increased analgesic effects of buprenorphine. Especially in group III, the pain level was significantly lower and number of doses of bupivacaine was significantly fewer than in group I. In conclusion, droperidol 2.5 mg continuously infused into epidural space increases analgesic effects of buprenorphine.

[The effect of dopamine and prostaglandin E1 on urine oxygen tension (PuO2)]

We reported that PuO2 reflects renal medullary perfusion and decreases during N2O-O2 isoflurane (GOI) or sevoflurane (GOS) anesthesia. In the present study, we examined the effect of dopamine (DOA) or prostaglandin E1 (PGE1) on PuO2 during GOI anesthesia. Twenty four patients from elective surgery with GOI anesthesia were randomly divided into three groups, i.e. control group (n = 8), DOA group (n = 8) and PGE1 group (n = 8). PuO2 decreased significantly in the control group, while in the DOA and PGE1 groups, PuO2 was unchanged. These results suggest that DOA and PGE1 maintain renal medullary perfusion under GOI anesthesia.

[Changes in analgesic levels, plasma concentrations and epidurogram during long-term continuous epidural block]

The change of analgesic levels, plasma concentrations and the radiographical changes of epidural space due to continuous epidural block were studied in 54 patients receiving pain relief. All the patients received 2 ml per hour of 2% lidocaine or 0.5% bupivacaine via the catheter over two weeks. The effect of epidural block was determined on 1, 2, 4, 7, 10 and 14 days, the epidurogram was performed on 1, 7, 14 days, and plasma concentration of lidocaine or bupivacaine was measured on 1, 3, 7, 14 days. We removed catheters in 8 patients because of infection around the catheter, pain in the back during injection, the leakage of anesthetics, and spontaneous removal. The effects and plasma concentrations of epidural block decreased significantly after a week, and the mean segmental number of radiographic spread decreased significantly after two weeks. The decreasing effect or duration of epidural block was due to decrease in spread of anesthetics because of adhesion around the catheter in the epidural space. We conclude that the safety period of continuous epidural block is within 2 weeks.

[The effect of flumazenil in reversing midazolam, flunitrazepam or diazepam]

In 31 adult patients who had undergone spinal or epidural anesthesia, we evaluated the effect of flumazenil in reversing midazolam, flunitrazepam or diazepam. The patients received midazolam 5 mg, flunitrazepam 1 mg or diazepam 5 mg 15 min after the spinal or epidural anesthesia. After the completion of operation, flumazenil (0.2 mg-1.0 mg) was administered until the patient became awake. Blood pressure, pulse rate and respiratory rate before and after administration of flumazenil showed no statistically significant changes in these groups. There were no significant differences in necessary amount of flumazenil among these groups. The time necessary for the patient to be awake in midazolam group was significantly shorter than that in flunitrazepam or diazepam group. Half of the patients in flunitrazepam and diazepam groups slept again after leaving the operating room, but they presented no clinical problems. In conclusion, we consider that flumazenil does not affect circulation and respiration, so it seems to be safe and effective for reversing benzodiazepins in clinical situation.

[The evaluation of cuff-occluded rate of rise of peripheral venous pressure (CORRP) for monitoring blood volume status]

Cuff-occluded rate of rise of peripheral venous pressure (CORRP) was evaluated for perioperative monitoring. We investigated the CORRP in 6 patients undergoing open laparotomy. These patients were given general anesthesia, and monitoring lines were inserted. Heart rate, blood pressure (BP), right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure (PAP), cardiac output (CO) and CORRP were monitored. CORRP is defined as the average rate (in millimeters of mercury per minute) of rise of peripheral venous pressure after proximal occlusion of that vein by a tourniquet (select pressure: 50 mmHg). In the actual measurement of CORRP, only the first 90% of the curve after occlusion of the tourniquet is used. CORRP correlated with RAP (r = 0.69 +/- 0.10), and PCWP (r = 0.79 +/- 0.07). On the other hand, there was no significant correlation between CORRP and BP, or PAP and CO. Snyder et al. described that CORRP seems to be an excellent indicator of acute volume change in the hyper- and hypovolemic canine model. We conclude that in these laparotomy patients, CORRP appears to be a sensitive and minimally invasive method of assessing volume status.

[Use of ketamine combined with local anesthetics in epidural anesthesia]

Postoperative pain relief and sedation with epidural ketamine were studied. Twenty-four patients for elective upper abdominal surgery were divided into 4 groups. Epidural catheter was inserted into thoracic epidural space before induction of general anesthesia. In each group, either 0.25% bupivacaine 5 ml only, ketamine 0.1 mg.kg-1 + bupivacaine 5 ml, or ketamine 0.3 mg.kg-1 + bupivacaine 5 ml, or ketamine 0.5 mg.kg-1 + bupivacaine 5 ml was injected into epidural catheter for complaint of pain in recovery room. In ketamine injected groups, blood pressure and heart were unchanged, but respiration rate increased significantly. Patients in ketamine 0.3 or 0.5 mg.kg-1 injected groups, pain relief and sedation score were significantly intensified, but patients in ketamine 0.5 mg.kg-1 injected group, incidence of pain in the back during injection and headache was high. We conclude that epidural ketamine is useful for postoperative pain relief, and the superior dose of epidural ketamine is 0.3 mg.kg-1.

[Problems of epidural droperidol administration]

We describe three cases of extrapyramidal reactions apparently caused by epidural administration of droperidol. These patients suffered from chronic pain and was treated with epidural lidocaine and droperidol. Two patients received continuous administration of droperidol, and experienced acute dystonia and another after a single dose, developed akathisia. Adverse reactions occurred at 15, 20 and 24 hours after the administration of droperidol. The first patient received droperidol 6 mg, the second 8.5 mg and the third 5 mg. We consider that extrapyramidal reactions are due to overdoses because the patients who had been given less than 2.5 mg of droperidol a day, showed no adverse reaction. Although we use higher doses with NLA or for management of fever than with epidural administration of droperidol, we seldom encounter cases of side effects with droperidol. Epidurally administrated droperidol spreads rostral within the neuraxis and causes delayed extrapyramidal reactions as epidural morphine develops delayed respiratory depression. We must be careful in caring patients suffering from chronic pain with continuous epidural administration of droperidol.

Clavicular approach to intraosseous infusion in adults

We attempted a clavicular approach to intraosseous infusion (clavicular IO) as a new procedure in adults, and compared the flow rates of subclavian venous infusion, and clavicular, iliac and tibial IO. Furthermore, we observed enhanced roentgenograms of each IO by contrast media. As a result, clavicular IO indicated 11.9 +/- 0.68 mL/kg/hr (mean +/- SD, n = 29), iliac IO 32.2 +/- 4.48 (n = 21), tibial IO 18.9 +/- 1.28 (n = 15), and subclavian venous infusion 15.2 +/- 1.48 (n = 15). There were no statistically significant differences between subclavian venous infusion and clavicular IO. In roentgenograms, the contrast media entered the inferior vena cava from iliac IO, and via the femoral vein by tibial IO. The superior vena cava was enhanced through the subclavian vein in clavicular IO. No complications such as fractures or transclavicular penetrations by the IO needle occurred. In conclusion, clavicular IO may be an alternative infusion technique to provide the fluids into the subclavian vein in adults.

[Changes in urine oxygen tension (PuO2) during anesthesia with isoflurane and sevoflurane]

Leonhardt and coworkers have suggested that PuO2 may indicate degree of renal medullary perfusion and function. The changes in PuO2 during N2O-O2-isoflurane anesthesia (GOI) and N2O-O2-sevoflurane anesthesia (GOS) were studied in 20 patients (GOI group: 10 cases, GOS group: 10 cases) who underwent elective surgeries. In the GOI group, PuO2 decreased significantly 30 and 60 minutes after the beginning of surgical incision, and it returned to the previous value immediately after the cessation of isoflurane. In the GOS group PuO2 decreased starting 30 minutes after the beginning of surgical incision until 10 minutes after the cessation of sevoflurane. These results suggest that isoflurane and sevoflurane administration caused a reduction in renal medullary perfusion, and that the low perfusion during sevoflurane anesthesia lasted longer than during isoflurane anesthesia. Measurement of PuO2 has a number of problems, but we believe that PuO2 is useful as an indicator of renal medullary blood flow.

Systematic management of graft-versus-host disease (GVHD)

Patients with graft-versus-host disease (GVHD) develop multiple organ failure (MOF), so systematic management is needed. First, patients should be kept in a clean room. Antibiotics, anti-fungal drugs and gamma-globulins are essential for the prevention and treatment of infections. If patients are hypoxic for the nasal cannula or the mask, continuous positive airway pressure (CPAP) or artificial ventilation must be used. In the treatment of hepatic dysfunction, lactulose, branched chain amino acid, glucagon-insulin, and Prostaglandin E1 (PGE1) are given. If plasma exchanges are ineffective, a bilirubin absorption therapy may remain partially effective. In the treatment of renal failure, diuretics, PGE1 and dopamine are given. Hemofiltration and hemodialysis will be effective. But the effective treatment for post-transfusion GVHD is unavailable, so systematic management of GVHD is no more than allopathic treatment.

[P50, 2,3-diphosphoglycerate and sodium as well as potassium in red blood cells in the perioperative period after hemodilutional autotransfusion]

The changes of the P50, 2,3-DPG and sodium as well as potassium of red blood cells in perioperative period were studied in 12 patients who underwent hemodilutional autotransfusion (HAT). P50 and 2, 3-DPG did not show remarkable changes before the third day after operation, but increased significantly on 5th and 7th day. There was a positive correlation between P50 and 2,3-DPG. Potassium of red blood cell increased significantly except on the first day. But sodium of red blood cell showed no remarkable change. In conclusion, our data demonstrate that the tissue oxygen supply from the red blood cell is maintained, because P50 did not decrease. Sodium in the red blood cell does not show remarkable changes, and therefore the membrane function of the red blood cell should be kept intact.

[Postoperative respiratory functions after laparoscopic cholecystectomy]

We studied the influences of the laparoscopic cholecystectomy (LC) on the postoperative pulmonary functions by performing respiratory function tests, blood gas analysis and the measurement of the rib cage contributions (RCC). LC resulted in less postoperative pulmonary dysfunctions compared with laparotomic cholecystectomy. After LC, vital capacity and PaO2 were not markedly affected, and RCC remained low. After LC, hospitalization was shorter, LC does not injure the abdominal muscles of the patients, and preserves the function of the diaphragm. In addition, it gives less wound pains. Therefore, we conclude that LC has many advantages for patients, especially for those with complications, and it will be used more in the near future.

[Evaluation of the peripheral circulation during surgery by the difference between the central and peripheral temperature]

The peripheral circulation during surgery was evaluated by the difference between rectal and sole deep temperature (RT-SDT) in 160 patients. Moreover it was investigated whether the peripheral circulation is influenced by the operation site, the method of anesthesia, the age of patient, the volume of infusion and blood loss. In many patients during intracranial, thoracic and upper abdominal surgeries, RT-SDT dissociated with time. But the change of RT-SDT varied with the anesthetic method. During upper abdominal surgery, RT-SDT tended to dissociate wtih the halothane (H) or enflurane (E)+N2O anesthesia and the wide dissociation was observed with fentanyl+droperidol+N2O anesthesia (NLA) on and after the 4th hour during the surgery. In contrast, RT-SDT continued to converge throughout the surgery in H or E+N2O+epidural anesthesia. The influence on RT-SDT of age, volume of infusion and blood loss, varied with the anesthetic method also. RT-SDT on the 4th hour during surgery correlated with the age of the patient, the volume of infusion in the H+N2O anesthesia, and with the volume of blood loss under NLA. The peripheral circulation during the surgery is affected seriously by anesthesia and the site as well as time of the operation. Therefore the anesthetic method should be selected in consideration of the type, length and site of operation. Some counter-measures should be taken in order to maintain good peripheral circulation in long operations.

[Clinical examination of acetated Ringer solution in patients with normal liver function and those with liver dysfunction]

Acetated Ringer solution (AR) was studied clinically to find its usefulness in patients with liver dysfunction compared with lactated Ringer solution (LR). The thirty-eight patients scheduled to be operated were divided into four groups (Group I: with normal liver function and AR infused, Group II: with normal liver function and LR infused, Group III: with liver dysfunction and AR infused, Group IV: with liver dysfunction and LR infused). AR or LR was administered to each group at a speed of 10 ml.kg-1.h-1, and we investigated the differences of these four groups clinically. L-lactic acid increased significantly in all groups after administration of AR or LR. D-lactic acid increased in LR groups, and acetic acid increased in AR groups. However, the other parameters, including the acid-base balance, electrolytes and liver function, showed no significant changes in any group. Therefore the status of liver dysfunction did not affect the metabolism of lactic acid in this study. These findings indicate that as an intraoperative fluid, AR is just as useful as LR. However, there was no significant difference between the data of AR groups compared with those of LR groups. In conclusion, AR is not necessarily a better fluid compared with LR as an intraoperative fluid in patients with liver dysfunction.

[A study of postoperative respiratory function]

The purpose of this study is to investigate the causes of postoperative respiratory failure from the point of view of respiratory movement and respiratory function, using a respigraph. Thirty patients who had laparotomy, thoracotomy or both were studied. A-aDo2 increased after operation. The values recovered slowly in the order of thoracotomy, laparotomy, was thoraco-laparotomy group. Percent vital capacity (% VC), one second timed force expiratory volume (FEV1), and peak expiratory flow (PEF) were suppressed immediately after operations and increased slowly, but showed still lower values even on the 7th day. VT, V min, f, TI/TT, VT/TI and PaCO2 were almost at the same levels among the three groups. Percent rib cage (% of RC) increased and remained high on the 7th day after laparotomy and thoraco-laparotomy, but showed no remarkable changes after thoracotomy. Between A-aDo2 and % RC in laparotomy group, there was a good correlation. Not only FRC but also the change of % RC seemed to have caused postoperative hypoxemia. The movement of the abdomen affected respiratory dysfunction more than the movement of the thorax after thoracic and abdominal surgery.

[Effects of mannitol on the function of red blood cells]

The effects of mannitol on the function of red blood cell were studied in 12 neurosurgical patients for 4 hours after intravenous administration of 2 g.kg-1 mannitol taking 30 min. After the administration of mannitol, osmotic pressure, Na and K in serum and of red blood cell were all altered. P50, 2, 3-DPG rose gradually and red blood cell deformity improved significantly. These results indicate that mannitol can shift oxyhemoglobin dissociation curve rightward, improve red blood cell deformity, and increase tissue oxygenation significantly. Mannitol administration not only decreases intracranial pressure but also improves peripheral circulation and oxygen transport during brain resuscitation.

Selective pulmonary vasodilatory effect of ZSY-27 in dogs with pulmonary hypertension due to pulmonary embolism

The pulmonary vasodilator effect of ZSY-27, a newly synthesized phosphodiesterase inhibitor, was studied in dogs with pulmonary hypertension resulting from autologous muscle-induced pulmonary embolism (PE). A bolus injection of ZSY-27 (1 mg/kg) significantly decreased mean pulmonary arterial pressure from 32 +/- 4 to 24 +/- 5 mm Hg and pulmonary vascular resistance index from 415 +/- 60 to 316 +/- 94 dyne.sec/cm5.m2. ZSY-27 did not change mean arterial pressure. The cardiac index was slightly increased and the systemic vascular resistance index was slightly decreased after ZSY-27 injection, but these changes were not statistically significant. This study suggests that ZSY-27 is a possible therapeutic agent for pulmonary hypertension secondary to PE.

Importance of anticomplement immunofluorescence antibody titration for diagnosing varicella-zoster virus infection in Bell's palsy

Anticomplement Immunofluorescence was used for antibody titration against varicella-zoster virus (VZV) in 43 patients with peripheral facial palsy. Nine of 31 patients (29%) with Bell's palsy and eight of 12 patients (75%) with Ramsey-Hunt syndrome had anticomplement immunofluorescence antibody titres of greater than or equal to 1/10. On the other hand, none of 14 patients with herpes simplex virus (HSV) infection and 51 healthy adults showed anticomplement immunofluorescence antibody titres of greater than or equal to 1/10. The anticomplement immunofluorescence antibody titre in two patients with Ramsey-Hunt syndrome increased later and decreased sooner than the indirect immunofluorescence antibody titre, becoming undetectable at 66 and 104 days, respectively, after onset of the disease. There was no cross reaction between anti-VZV and anti-HSV antibodies in the patients who showed a positive antibody rise for VZV. As the acute stage of VZV infection is obscure in the patients with peripheral facial palsy without herpes the screening of anticomplement immunofluorescence antibody to VZV at titres greater than or equal to 1/10 may be useful for the diagnosis of VZV infection in patients with peripheral facial palsy.

A newly designed flexible fiberoptic bronchoscope for use in intensive care units

A newly designed flexible fibroptic bronchoscope has been manufactured for use in intensive care units (ICU). It has an inside channel of large caliber, diameter 2.5 mm, through which pulmonary secretions can be aspirated directly via the suction tube. Furthermore, prompt bedside use is possible since handle type batteries can easily be attached to the bronchofibroscope. This new instrument is now employed in our ICU for: 1. The diagnosis and treatment of atelectasis. 2. Suction of retained secretions. 3. Detection of tracheal obstruction. 4. Evaluation of endotracheal and tracheostomy tubes whilst in position. 5. Observation of tracheal and bronchial changes. 6. Help in endotracheal intubation. It was used most frequently for the diagnosis and treatment of atelectasis and suction of retained secretions.

Effects of dibutyryl cyclic-AMP on cardiac output and myocardial contractility in dogs

Dibutyryl cyclic-AMP was administered to a group of anesthetized dogs at the doses of 5, 10, 20 and 40 mg/kg, and changes in stroke volume, cardiac output and myocardial contractility were observed. Also, effects of this substance on contractile performance of isolated cardiac muscle were investigated in another group of dogs. Results were as follows: 1) Dibutyryl cyclic-AMP increased heart rate, stroke volume and cardiac output in a dose-related manner in the range from 5 to 40 mg/kg. 2) As indices of myocardial contractility, Vmax and maximum dF/dt were examined. These also showed a dose-dependent increase in response to dibutyryl cyclic-AMP. In isolated dog hearts, dibutyryl cyclic-AMP raised the maximum velocity of shortening (V'max) dose-dependently. 3) Total peripheral resistance declined in a dose-related way. On the other hand, mean arterial pressure and CVP dropped slightly without showing dose-dependence. These results show that dibutyryl cyclic-AMP produces positive inotropic and chronotropic effects and cause dilatation of the peripheral vessels in dose-dependent manners.

Responses to exogenous dibutyryl adenosine 3',5'-monophosphate of cardiac output and blood flow in the renal, superior mesenteric and carotid arteries in anesthetized dogs

Changes in the cardiac output and blood flow in the renal, superior mesenteric and carotid arteries in anesthetized dogs were observed, using the non-cannulating electromagnetic flow meter. Dibutyryl cyclic-AMP, 5 mg/kg body weight, was given intravenously and the following results were obtained: 1) Dibutyryl cyclic-AMP increased the stroke volume and the cardiac output, and slightly increased the heart rate. These effects appeared 3 to 5 min after administration of dibutyryl cyclic-AMP. 2) The mean systemic blood pressure as well as the central venous pressure fell slightly. 3) The renal and the superior mesenteric artery blood flow increased markedly, but the carotid artery blood flow did not change. 4) Distribution of the cardiac output to the renal and superior mesenteric arteries did not change but distribution to the carotid artery decreased. 5) Total peripheral resistance, renal artery vascular resistance and superior mesenteric artery vascular resistance decreased, and carotid artery vascular resistance decreased slightly. 6) The cardiac output and blood flow were enhanced by aminophylline (3 mg/kg), and were not blocked by propranolol (0.3 mg/kg).