Fatal Severe Fever with Thrombocytopenia Syndrome Virus and Pasteurella multocida Coinfection

We herein report a case of severe fever with thrombocytopenia syndrome (SFTS) with Pasteurella multilocida bacteremia in a 65-year-old man with alcoholic cirrhosis who was admitted to our hospital with anorexia and severe fatigue. Laboratory tests revealed pancytopenia and liver and kidney dysfunction. After admission, he developed impaired consciousness, mucosal hemorrhaging, and septic shock. SFTS virus was detected on polymerase chain reaction testing of blood and throat swabs, and Pasteurella multocida was detected on blood culture. Despite being treated with invasive mechanical ventilation, vasopressors, and antibiotics, the patient's condition progressively deteriorated, and he died four days after admission.

Hypertension and advanced age increase the risk of cognitive impairment after mild traumatic brain injury: A registry-based study

OBJECTIVE

As the global population ages, the incidence of traumatic brain injury (TBI) increases. While mild TBI can impair the cognitive function of older adults, the cause and background of mild TBI-induced cognitive impairment remains unclear, and the evaluation of risk factors for cognitive impairment after mild TBI remain open for consideration especially in the current aging society. This study aimed to evaluate the risks associated with cognitive impairment following mild TBI.

METHODS

Between January 2006 and December 2018, 2,209 patients with TBI required hospitalization in Shimane Prefectural Central Hospital. Mild TBI was defined as a Japan coma scale ≤ 10 at admission. The cognitive function of the patients was measured with the Hasegawa Dementia Rating Scale-revised or Mini-mental state examination at least twice during the patients' hospital stays. The odds ratio (OR) and 95% confidence interval (CI) of each considered risk factor was calculated with multivariable logistic regression analysis after univariate analysis.

RESULTS

Among 1,674 patients with mild TBI, 172 patients underwent cognitive function examinations, and 145 patients (84.3%) were found to have cognitive impairment at discharge. Significant risk factors for cognitive impairment included age (P = 0.008) and hypertension (P = 0.013) in univariate analysis; and age (OR 1.04: 95% CI 1.01-1.07) and hypertension (OR 5.81: 95% CI 1.22-27.68) by multivariable analysis.

CONCLUSIONS

Older patients with hypertension displayed significantly higher cognitive impairment risk after even mild TBI. For these patients, we should take carefully management even after mild TBI.

A case of lip edema caused by the accidental ingestion of a bar of soap

The most common symptom following the accidental ingestion of a soap is lip edema. Although most cases are asymptomatic or exhibit mild symptoms, in some cases, aspiration pneumonia, oropharyngeal edema, and bronchial obstruction may be fatal.

The characteristics, types of intervention, and outcomes of postoperative patients who required rapid response system intervention: a nationwide database analysis

Purpose

Improving the safety of general wards is a key to reducing serious adverse events in the postoperative period. We investigated the characteristics, treatment, and outcomes of postoperative patients managed by a rapid response system (RRS) in Japan to improve postoperative management.

Methods

This retrospective study analyzed cases requiring RRS intervention that were included in the In-Hospital Emergency Registry in Japan. We analyzed data reported by 34 Japanese hospitals between January 2014 and March 2018, mainly focusing on postoperative patients for whom the RRS was activated within 7 days of surgery. Non-postoperative patients, for whom the RRS was activated in all other settings, were used for comparison as necessary.

Results

There were 609 (12.7%) postoperative patients among the total patients in the registry. The major criteria were staff concerns (30.2%) and low oxygen saturation (29.7%). Hypotension, tachycardia, and inability to contact physicians were observed as triggers significantly more frequently in postoperative patients when compared with non-postoperative patients. Among RRS activations within 7 days of surgery, 68.9% of activations occurred within postoperative day 3. The ordering of tests (46.8%) and fluid bolus (34.6%) were major interventions that were performed significantly more frequently in postoperative patients when compared with non-postoperative patients. The rate of RRS activations resulting in ICU care was 32.8%. The mortality rate at 1 month was 16.2%.

Conclusion

Approximately, 70% of the RRS activations occurred within postoperative day 3. Circulatory problems were a more frequent cause of RRS activation in the postoperative group than in the non-postoperative group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-021-02900-4.

Prevalence and predictors of direct discharge home following hospitalization of patients with serious adverse events managed by the rapid response system in Japan: a multicenter, retrospective, observational study

AIM

The rapid response system (RRS) is an in-hospital medical safety system. To date, not much is known about patient disposition after RRS activation, especially discharge home. This study aimed to investigate the prevalence, characteristics, and outcomes of patients with adverse events who required RRS activation.

METHODS

Retrospective data from the In-Hospital Emergency Registry in Japan collected from April 2016 to November 2020 were eligible for our analysis. We divided patients into Home Discharge, Transfer, and Death groups. The primary outcome was the prevalence of direct discharge home, and independently associated factors were determined using multivariable logistic regression.

RESULTS

We enrolled 2,043 patients who met the inclusion criteria. The prevalence of discharge home was 45.7%; 934 patients were included in the Home Discharge group. Age (adjusted odds ratio [AOR] 0.96; 95% confidence interval [CI], 0.95-0.97), malignancy (AOR 0.69; 95% CI, 0.48-0.99), oxygen administration before RRS (AOR 0.49; 95% CI, 0.36-0.66), cerebral performance category score on admission (AOR 0.38; 95% CI, 0.26-0.56), do not attempt resuscitation order before RRS (AOR 0.17; 95% CI, 0.10-0.29), RRS call for respiratory failure (AOR 0.50; 95% CI, 0.34-0.72), RRS call for stroke (AOR 0.12; 95% CI, 0.03-0.37), and intubation (AOR 0.20; 95% CI, 0.12-0.34) were independently negative, and RRS call for anaphylaxis (AOR 15.3; 95% CI, 2.72-86.3) was positively associated with discharge home.

CONCLUSION

Less than half of the in-hospital patients under RRS activation could discharge home. Patients' conditions before RRS activation, disorders requiring RRS activation, and intubation were factors that affected direct discharge home.

Clinical characteristics of pyogenic spondylitis and psoas abscess at a tertiary care hospital: a retrospective cohort study

Background

Psoas abscess and pyogenic spondylitis are intractable diseases that require long-term treatment, but the clinical characteristics and causative organisms have not been fully investigated. Herein, we describe the clinical characteristics of these diseases and evaluate the factors associated with in-hospital mortality and the presence of gram-negative rods as causative microorganisms.

Methods

All patients diagnosed with pyogenic spondylitis or psoas abscesses at a tertiary hospital were included. We retrieved the clinical data (age, sex, outcome, length of hospital stay, disease, bacteria, medication, comorbidities, and treatment status), vital signs (blood pressure, heart rate, and body temperature), and laboratory test results (blood cell count, liver function, renal function, electrolytes, blood sugar, and C-reactive protein) of all patients. The outcomes were in-hospital deaths and positive cultures of gram-negative rods.

Results

We analyzed 126 patients consisting of 69 (55%) men with a population mean age of 72 years. Seventy-two patients had pyogenic spondylitis and 54 had psoas abscesses. Eleven patients (8.3%) died during admission. The causative bacteria were gram-positive cocci in 63 patients (50%) and gram-negative bacteria in 19 patients (15%). The multivariate logistic model showed that blood urea nitrogen (BUN) (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02–1.06) and cardiovascular diseases (OR 7.02, 95% CI 1.55–31.8) were associated with in-hospital mortality. Platelets less than 150,000/μL (OR 3.14, 95% CI 1.02–9.65) and higher aspartic aminotransferase (OR 1.02, 95% CI 1.00–1.03) were associated with gram-negative rods.

Conclusions

Patients with suspected psoas abscesses or pyogenic spondylitis having a high BUN level and a history of cardiovascular diseases have a higher risk of mortality.

Fatal case of ST8/SCCmecIVl community-associated methicillin-resistant Staphylococcus aureus infection in Japan

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) with ST8/SCCmecIV threatens human health. However, its pathogenesis remains unclear. ST8 CA-MRSA (CA-MRSA/J) with SCCmecIVl, which carries the large LPXTG-motif-containing putative adhesin gene, spj, has emerged in Japan. We present the first reported case of death from CA-MRSA/J. The patient was a 64-year-old woman with iliopsoas abscesses complicated by septic pulmonary embolism and multiorgan abscesses. Vancomycin, arbekacin, daptomycin and rifampicin were ineffective. CA-MRSA/J was resistant to erythromycin, clindamycin and antiseptics and was invasive in a HEp-2 cell assay, in contrast to skin-derived villous-adherent CA-MRSA/J. This suggests the strongly invasive pathotype of CA-MRSA/J.

Streptococcal toxic shock syndrome from necrotizing soft-tissue infection of the breast caused by a mucoid type strain

Streptococcal toxic shock syndrome is a severe infectious disease. We report a Japanese case of Streptococcal toxic shock syndrome caused by a highly mucoid strain of Streptococcus pyogenes. A 31-year old female with shock vital sign presented at a tertiary medical center. Her left breast was necrotizing and S. pyogenes was detected by Immunochromatographic rapid diagnostic kits. Intensive care, including administration of antibiotics and skin debridement, was performed. After 53 days in our hospital, she was discharged. The blood cultures and skin swab cultures all grew S. pyogenes which displayed a highly mucoid morphology on culture media. In her course of the disease, the Streptococcus strain had infected two other family members. All of the strains possessed the T1 and M1 antigens, as well as the emm1.0 gene. As for fever genes, the strains were all positive for speA, speB, and speF, but negative for speC. All of the strains exhibited and the same pattern in PFGE with the SfiI restriction enzyme. The strain might have spread in the local area by the data from the Japanese Infectious Disease Surveillance Center. Immunochromatographic rapid diagnostic kits are very useful for detecting S. pyogenes. However, they can not be used to diagnose severe streptococcul disease by highly mucoid strain alone. Careful observation of patients and colony morphology are useful methods for diagnosing severe streptococcal disease by highly mucoid strain.

[Real-time PCR in rapid diagnosis of Aeromonas hydrophila necrotizing soft tissue infections]

We report a case of rapidly progressive necrotizing soft tissue infection and sepsis followed by a patient's death. We suspected Vibrio vulnificus infection because the patient's underlying disease was cirrhosis and the course extremely rapid. No microbe had been detected at death. We extracted DNA from a blood culture bottle. SYBR green I real-time PCR was conducted but could not detect V. vulnificus vvh in the DNA sample. Aeromonas hydrophila was cultured and identified in blood and necrotized tissue samples. Real-time PCR was conducted to detect A. hydrophila ahh1, AHCYTOEN and aerA in the DNA sample extracted from the blood culture bottle and an isolated necrotized tissue strain, but only ahh1 was positive. High-mortality in necrotizing soft tissue infections makes it is crucial to quickly detect V. vulnificus and A. hydrophila. We found real-time PCR for vvh, ahh1, AHCYTOEN, and aerA useful in detecting V. vulnificus and A. hydrophila in necrotizing soft tissue infections.

Pyogenic liver abscess caused by Klebsiella pneumoniae genetic serotype K1 in Japan

Pyogenic liver abscess caused by Klebsiella pneumoniae is an emerging disease worldwide, and we know the serotype K1 strain to be the most virulent strain. We report a Japanese case of septic pyogenic liver abscess caused by K. pneumoniae genetic serotype K1. A 60-year old man presented at our hospital in a state of cardiopulmonary arrest. From the patient's chief complaint of chest pain, we suspected acute coronary syndrome, i.e., acute myocardial infarction. We used extracorporeal circulation and checked coronary angiography, but the 75% stenosis by itself could not adequately account for the patient's critical condition. The patient's laboratory data indicated multiple organ failure. The patient's condition did not improve while in intensive care and he died 20 h after the onset of the cardiopulmonary arrest. Pathological autopsy later showed colliquative necrosis in the deltoid and left greater pectoral muscles, as well as liver abscesses. The patient's blood, gastric juice, and stool cultures all grew a Gram-negative bacillus identified as Klebsiella pneumoniae. We also performed capsular polysaccharide synthesis (cps) genotyping by polymerase chain reaction for the detection of K serotype-specific alleles at the wzx and wzy loci. The result indicated that wzx_K1 and wzy_K1 were positive. This is the first reported Japanese case of septic pyogenic liver abscess caused by K. pneumoniae genetic serotype K1.

[An analysis on blood transfusion for hepatic resection]

BACKGROUND

Hepatic resection is prone to significant blood loss. Adverse effects of blood loss and transfusion mandate improvements in surgical techniques to reduce blood loss and transfusion.

METHODS

We retrospectively analyzed the present status of intraoperative blood transfusion practice of 42 hepatic resections in National Kure Medical Center for the year of 2000.

RESULTS

Median values for blood loss were 1355, 1708, 1415, and 2298 ml for nonanatomic, subsegmental, segmental and extended right resections, respectively. Crossmatched to transfused blood (C/T) ratios were 1.76, 1.19, 2.31, and 0.90 for nonanatomic, subsegmental, segmental and extended right resections, respectively.

CONCLUSION

In general, C/T ratio of 1.5 to 2.5 has been recommended but own C/T ratios are 1.19 and 0.9 for subsegmental and extended right hepatic resection, which are lower than recommended values. It was estimated that inappropriate prediction of blood loss by several surgeons and unused maximum surgical blood order schedule (MSBOS) or type and screen (T&S) decreased these values of C/T ratio in the present analysis. We therefore conclude that MSBOS and T&S could be improved by avoiding such in appropriate prediction.

[Bronchospasm during crush induction with propofol under the Sellick maneuver in a patient for emergency laparotomy]

A 61-year-old man was scheduled for an emergency laparotomy due to ileus. He had a history of asthma, but it was well controlled without medication. Anesthesia was induced with propofol and ketamine under the Sellick maneuver. Following administration of vecuronium, endotracheal intubation was performed. However, he could not be ventilated. We thought that the tube had been inserted into the esophagus, and re-intubation was performed. However he could not be ventilated as in the first trial. At that time, we suspected that bronchospasm had occurred. Bronchospasm improved rapidly using hyperventilation with 100% oxygen and 3-5% sevoflurane, and intravenous aminophylline. Because he had a history of asthma, propofol was relatively indicated from the point of smooth muscle relaxant effects. However we should consider the risk of bronchospasm in a patient with a history of asthma, even if we use propofol.

[Safety of continuous epidural anesthesia during heart surgery--change of coagulation-fibrinolysis under heparinization]

To confirm the safety of continuous epidural anesthesia during extracorporeal circulation under heparinization, we investigated epidural hematoma formation following the cardiopulmonary bypass in both humans and dogs. In fifteen dogs, divided into three groups, heparin was administered at the dose of 300, 600, or 900 U.kg-1, respectively. In fourteen patients, a dose of 300 U.kg-1 haparin was administered for cardiopulmonary bypass. Although blood coagulation-fibrinolysis dropped into abnormal ranges following heparinization, no epidural hematoma was observed in dog and no patient revealed spinal complication associated with epidural hematoma. These data indicate that continuous epidural anesthesia would be a safe tool for intraoperative anesthesia even during extracorporeal circulation under heparinization.

Cutaneous responsiveness of lumbar spinal dorsal horn neurons is reduced by general anesthesia, an effect dependent in part on GABAA mechanisms

Extracellular activity was recorded from single spinal dorsal horn neurons in both chronic cat and acute rat models. This was done to define the effects of anesthesia on the processing of sensory information elicited by nonnoxious tactile stimulation of peripheral receptive fields (RFs). In the chronic cat model, baseline data were obtained in physiologically intact, awake, drug-free animals before anesthetic administration (halothane 1.0-2.0%). This made it possible to compare and contrast activity of each cell in the drug-free and anesthetized state. Halothane effects were confirmed in the acute rat model (anesthetized, spinally transected, and in some cases decerebrate). In addition, the gamma-aminobutyic acid-A (GABAA)-receptor antagonist picrotoxin (2 mg/kg) was administered intravenously to verify that the observed halothane effect on spinal dorsal horn neurons was mediated by an interaction with GABAA-receptor systems. Halothane effects on three separate measures of response to nonnoxious tactile stimuli were observed in the chronic cat model. Halothane produced a significant, dose-dependent reduction in the low-threshold RF area of the neurons studied. Halothane also caused a significant reduction in neuronal response to RF brushing (dynamic stimulus) and to maintained contact with the RF (static stimulus). A dose dependency was not observed with these latter two effects. Neurons with a predominant rapidly adapting response seemed to be less susceptible to halothane suppression than slowly adapting cells. In the acute rat model an increase in halothane caused a reduction in neuronal response similar to that seen in the cat. The intravenous administration of 2 mg/kg of picrotoxin by itself caused no significant change in RF size or response to brushing. However, the same amount of picrotoxin did cause a 50% reversal of the halothane-induced reduction in RF size without causing a significant change in the halothane effect on response to RF brushing. In contrast to work recently reported in a chronic sheep model, halothane causes a significant reduction in spinal dorsal horn neuronal response to tactile stimulation of peripheral RFs. This effect is caused by, in part, but not exclusively, to GABAA-neurotransmitter systems. However, the relative influence of GABAA systems may vary with the nature of the stimulus.

Spinal Anesthesia With Tetracaine in 0.75% Glucose: Influence of the Vertebral Interspace Used for Injection

Background and Objectives

The anesthetic behavior and hemodynamic consequences of spinal anesthesia with marginally hyperbaric tetracaine containing a low concentration of glucose injected at two different interspaces were examined and compared with those of conventionally hyperbaric solution.

Methods

One-hundred twenty ASA Physical Status I or II patients scheduled for elective surgery to the lower limb were sequentially assigned to one of three equal groups to receive spinal anesthesia: Group 1 received 0.5% tetracaine in 0.75% glucose with 0.125% phenylephrine at the L2-L3 interspace; group 2 0.5% tetracaine in 0.75% glucose with 0.125% phenylephrine at the L3-L4 interspace; group 3 0.5% tetracaine in 7.5% glucose with 0.125% phenylephrine at the L3-L4 interspace. Neural block was assessed in a double-blinded manner by cold, pinprick, and touch sensation, and a modified Bromage scale after the injection of the study drug.

Results

Injection at the L2-L3 interspace produced significantly higher spread of analgesia [median T7 (10th, 90th percentiles T10, T4)] than injection at L3-L4 interspace [T10 (L1, T5)] when using the solution in 0.75% glucose. There were no significant differences in peak dermatomal levels between groups 1 and 3, but the number of patients who required ephedrine for the treatment of hypotension was larger in group 3.

Conclusions

A marginally hyperbaric tetracaine solution injected at the L2-L3 interspace with the patient in the lateral position produced greater extent of cephalad spread than that at the L3-L4 interspace. When compared to a conventionally hyperbaric tetracaine solution injected at the L3-L4 interspace, the marginally hyperbaric solution injected at the L2-L3 interspace caused less hemodynamic variability despite similar levels of maximum sensory block.

Spinal anesthesia with tetracaine in 0.75% glucose: influence of the vertebral interspace used for injection

BACKGROUND AND OBJECTIVES

The anesthetic behavior and hemodynamic consequences of spinal anesthesia with marginally hyperbaric tetracaine containing a low concentration of glucose injected at two different interspaces were examined and compared with those of conventionally hyperbaric solution.

METHODS

One-hundred twenty ASA Physical Status I or II patients scheduled for elective surgery to the lower limb were sequentially assigned to one of three equal groups to receive spinal anesthesia: Group 1 received 0.5% tetracaine in 0.75% glucose with 0.125% phenylephrine at the L2-L3 interspace; group 2 0.5% tetracaine in 0.75% glucose with 0.125% phenylephrine at the L3-L4 interspace; group 3 0.5% tetracaine in 7.5% glucose with 0.125% phenylephrine at the L3-L4 interspace. Neural block was assessed in a double-blinded manner by cold, pinprick, and touch sensation, and a modified Bromage scale after the injection of the study drug.

RESULTS

Injection at the L2-L3 interspace produced significantly higher spread of analgesia [median T7 (10th, 90th percentiles T10, T4)] than injection at L3-L4 interspace [T10 (L1, T5)] when using the solution in 0.75% glucose. There were no significant differences in peak dermatomal levels between groups 1 and 3, but the number of patients who required ephedrine for the treatment of hypotension was larger in group 3.

CONCLUSIONS

A marginally hyperbaric tetracaine solution injected at the L2-L3 interspace with the patient in the lateral position produced greater extent of cephalad spread than that at the L3-L4 interspace. When compared to a conventionally hyperbaric tetracaine solution injected at the L3-L4 interspace, the marginally hyperbaric solution injected at the L2-L3 interspace caused less hemodynamic variability despite similar levels of maximum sensory block.

[Postoperative brain infarction in a patient with the previous asymptomatic brain infarction]

We report a case of a postoperative brain infarction, in which an asymptomatic preoperative brain infarction was also revealed postoperatively. A 63-year-old man with bladder carcinoma was scheduled for the cystoplasty. The patient had no prominent preoperative abnormality. Anesthesia was maintained with isoflurane in N2O/oxygen combined with a spinal block and a continuous epidural block. Anesthesia lasted uneventfully for 16.5 hours. However, emergence from anesthesia was delayed. On the first postoperative day, motor aphasia and right hemiparalysis was confirmed. The computed tomography (CT) of the brain demonstrated a low density area in the frontoparietal region. The magnetic resonance imaging (MRI) indicated the corresponding lesion as the CT had demonstrated, and an old brain infarction in the parietal region. This meant that the patient had a history of asymptomatic brain infarction (ABI). Patients with ABI are considered to be a high-risk group for a brain infarction. It is important to evaluate the risk factors of brain infarction preoperatively and to minimize those risks during the operation. Maintenance of the cerebral perfusion pressure is imperative.

Antinociceptive effects of ONO-9902, an enkephalinase inhibitor, after visceral stress condition in rats

PURPOSE

The present study was designed to examine the antinociceptive effects of orally administered ONO-9902, an enkephalinase inhibitor, on both somatic and visceral pain after visceral stress conditions.

METHODS

Twenty six male rats were examined. Tail-flick (TF) and colorectal distension (CD) tests were used to determine somatic and visceral antinociceptive effects, respectively. Measurements were performed in rats under immediate post-stress conditions (group ST; n = 14) and in rats nor under stress conditions (group NST; n = 12). In the stressed group, the same device, CD, for visceral antinociceptive effects was used for visceral stress and was applied with an intracolonic pressure of 60 mmHg for 20 min after drug administration. The TF latency and CD threshold were measured before and at 30, 40, 50, 60 and 90 min after administration of ONO-9902 300 mg.kg-1 or distilled water.

RESULTS

Orally administered ONO-9902 did not produce any changes in the % maximum possible effect (%MPE) in either TF or CD tests in the unstressed group. In the stressed group, %MPE in the CD test increased 18% and 31% at 30 and 40 min, respectively, after oral administration of ONO-9902 compared with the control group (P < 0.05). However, %MPE to TF test did not alter even after the CD-induced stress condition.

CONCLUSION

These results suggest that ONO-9902 may have analgesic effects on visceral pain but not on somatic pain under immediate post-stress conditions.

Halothane effects on low-threshold receptive field size of rat spinal dorsal horn neurons appear to be independent of supraspinal modulatory systems

Recent evidence strongly supports the importance of spinal sites of action for the ability of general anesthetic agents to block response to noxious stimuli. This study was designed to examine possible spinal anesthetic effects on non-noxiously evoked activity. Three groups of rats were prepared for acute experiments in which the response of spinal dorsal horn neurons to low threshold receptive field (RF) stimulation was evaluated. In each animal in each group extracellular activity was recorded from a single spinal dorsal horn neuron. A low-threshold RF of each neuron and, at times, the sensitivity to low-threshold stimulation of multiple sites in the RF were determined under baseline conditions (light anesthesia or decerebrate). In Group 1, reversible cooling of the thoracic spinal cord in the presence of either 0.5% or 1% halothane anesthesia caused no change in RF size. However, an increase from 0.5% to 1% halothane caused a 53% decrease in RF size both in the presence and absence of a reversible cold block of the spinal cord. In Group 2, animals with spinal cords transected at the thoracic level had a similar change in low-threshold receptive field size (52%) when halothane concentrations were increased from 0.5% to 1%. Testing sensitivity within the RF areas indicated that the silenced areas at the fringe of the receptive field could still elicit activation of spinal dorsal horn neurons but at a higher threshold. In the final group of animals, decerebration and spinal cord transection allowed us to compare effects of 0.5% and 1% halothane with an anesthetic free baseline. Here, again, a dose-dependent reduction in RF area was observed although the baseline RFs were significantly smaller than those in Groups 1 and 2. These results demonstrate that the reduction in low-threshold receptive field size due to the administration of the inhalation anesthetic halothane occurs in the absence of descending modulation from supraspinal sites. This implicates the spinal dorsal horn as a potentially important site of action for general anesthetics. These results also support the spinal cord as an important tool to study the pharmacology responsible for anesthetic effects on sensory processing.

Low-threshold neuronal activity of spinal dorsal horn neurons increases during REM sleep in cats: comparison with effects of anesthesia

1. Cats were prepared for chronic recordings from the lumbar enlargement of the spinal dorsal horn. At the beginning of each recording session, a tungsten microelectrode was advanced through the dura in a physiologically intact, awake, drug-free animal, until amplitude discrimination provided a single neuron with a receptive field on the hindquarters. 2. Extracellular recordings of activity of each neuron were made during receptive field stimulation with tactile and thermal nonnoxious and noxious stimuli. 3. Baseline responses obtained in the awake state were compared with responses of the same neurons during slow-wave or rapid-eye-movement (REM) sleep. In a subpopulation of neurons, the effects of anesthesia (propofol, 7.5 mg/kg iv) were observed after the completion of sleep studies. 4. The low-threshold receptive fields of the seven neurons studied during REM sleep were all increased in size when compared with the baseline value. The average increase was 52.6% (range 26.2-96.7%). 5. The low-threshold receptive fields of the seven neurons studied during REM sleep were reduced by propofol anesthesia by an average of 49.1% (range 29-74%). 6. Neuronal response to receptive field brushing was observed in 15 neurons during REM sleep. The effect of propofol on receptive field brushing was observed in 8 of those neurons. In only one of those eight neurons were the effects of REM sleep and anesthesia in the same direction. 7. Changes in neuronal responses were less consistent during slow-wave sleep but still differed from changes induced by propofol.(ABSTRACT TRUNCATED AT 250 WORDS)

Utilization of a glucose/fructose/xylitol carbohydrate solution during surgery

The utilization of a 4:2:1 mixture of glucose, fructose, and xylitol (GFX) was studied by indirect calorimetry in patients undergoing abdominal surgery. Sixteen patients undergoing gastrectomy under general anesthesia received GFX intravenously at 0.25 g/kg h-1 during surgery. VO2, VCO2, and RQ were measured continuously for 150 min using an Engström metabolic computer, and urea nitrogen excretion was determined at 30-min intervals during surgery. Blood levels of glucose, fructose, and xylitol plateaued after 1 h. The RQ decreased over the first 90 min from 0.84 +/- 0.06 to 0.75 +/- 0.05 and then gradually increased to 0.79 +/- 0.04 at 150 min. VO2 did not change significantly over the 150-min period. From the RQ, VO2, and nitrogen excretion data, carbohydrate oxidation was estimated. The amount of carbohydrate oxidized was 9.7 +/- 6.9 g during the first 30-min period, 3.5 +/- 5.2 g during the 60 to 90-min period, and 7.5 +/- 4.5 g in the 120 to 150-min study period. Simultaneously, lipid oxidation increased. These observations suggest that the GFX solution is adequately metabolized during surgery and therefore may be a suitable energy source for patients.

Histological evidence for dissociation of lipid peroxidation and cell necrosis in bromotrichloromethane hepatotoxicity in the perfused rat liver

Bromotrichloromethane (CBrCl3)-induced hepatic lipid peroxidation and cell necrosis were studied histologically and biochemically, using isolated perfused livers from phenobarbital-pretreated rats. Lipid peroxidation was assessed by fuchsin staining of the liver slices and release of thiobarbituric acid reactive substances (TBARS) into the perfusate; necrosis was assessed by trypan blue uptake and lactate dehydrogenase (LDH) leakage. A good correlation was observed between the Schiff-positive reaction and TBARS release under various experimental conditions, supporting the validity of the fuchsin staining method for histological detection of lipid peroxidation. Lobular localization of lipid peroxidation and necrosis was as follows: Under high oxygen supply (95% O2-saturated buffer), infusion of CBrCl3 caused the Schiff-positive reaction in the pericentral to midzonal hepatocytes, irrespective of the direction of perfusion, but did not produce necrosis. Under low oxygen supply (20% O2) with retrograde perfusion, dissociation of lipid peroxidation and necrosis was observed, i.e., trypan blue uptake in the periportal zones and Schiff-positive staining in the pericentral hepatocytes. Thus, lipid peroxidation by itself may have a relatively minor role in the development of CBrCl3-induced acute hepatic cell death.

Histological detection of lipid peroxidation following infusion of tert-butyl hydroperoxide and ADP-iron complex in perfused rat livers

Lipid peroxidation was assessed histologically and biochemically in hemoglobin-free perfused rat livers using two different types of stimulators. The Schiff reaction of fuchsin with cellular aldehydes was used as a histological index for lipid peroxidation. t-Butyl hydroperoxide (BHP, 0.8 mM) infusion caused a rapid and sustained release of thiobarbituric acid reactive substances (TBARS) into the effluent perfusate for up to 60 min, which was accompanied by lactate dehydrogenase (LDH) leakage after 30 min. The Schiff positive foci were initially restricted to periportal zones and spread with time to whole areas, accompanied by periportal necrosis. Coinfusion of diphenyl-p-phenylenediamine suppressed the TBARS release, with negative fuchsin staining, but the LDH leakage was unaffected. Under retrograde perfusion, BHP produced pericentral staining and necrosis. With 2.5 mM ADP-100 microM Fe3+, little TBARS was released up to 60 min, even though the hepatic TBARS levels increased considerably by this time. By 90 min, marked TBARS release occurred, but LDH leakage remained low. Irrespective of the direction of perfusion, pericentral hepatocytes became Schiff positive after 30 min. The fuchsin staining method may be useful for detecting peroxidized zones of the liver lobules.

[Anesthetic management of caesarean section for the delivery of quadruplets]

Multiple gestation pregnancies are accompanied with risks for both mother and fetuses. Morbidity and mortality of both of them are increased compared with singleton pregnancies. We have presented a case of a 30-year-old parturient with quadruplets. The pregnancy had been complicated by premature labour, anemia, toxemia, coagulopathy, pulmonary congestion and malpresentation. On the 29th week of pregnancy, an elective Caesarean section was scheduled. There is no ideal anesthetic technique for quadruplets. In this case general anesthesia was chosen, because she had coagulopathy. The anesthesia and postoperative course were uneventful. The patient and the four babies had no complication nor sequela on their discharge. The anesthetic considerations for multiple gestation pregnancies were also discussed.

[Successful management of abdominal aortic aneurysm due to bacterial infection: report of a case]

A successful surgery of abdominal aortic aneurysm due to bacterial infection is described. The patient, 71-year-old man, had been suffering from high fever of unknown origin which had narrow escape with the several kinds of antibiotics about a month and more. During the antibiotic therapy in another hospital, he was diagnosed as an abdominal aortic aneurysm by whole body computed tomography. Immediately after the arrival to our hospital, digital subtraction angiography was done, and it showed a saccular aneurysm in the infrarenal abdominal aorta. Surgical removal of this aneurysm without opening of the aneurysmal wall was performed and the kitted dacron graft was used for aorto-biiliac anastomosis. The diagnosis of aneurysm due to bacterial infection was confirmed by bacteriological and pathological examinations. The patient in now surviving 17 months after operation. Abdominal aortic aneurysm due to bacterial infection is a serious disorder that generally carries grave prognosis. Complete removal of infected lesion without contamination and long-term follow-up with antibiotic chemotherapy are essential for this disease.