Practical guidelines for the response to perioperative anaphylaxis

Perioperative anaphylaxis is a severe adverse event during anesthesia that requires prompt diagnosis and treatment by physicians, including anesthesiologists. Muscle relaxants and antibiotics are the most common drugs that cause perioperative anaphylaxis in Japan, as in many countries. In addition, sugammadex appears to be a primary causative agent. Obtaining previous anesthesia records is necessary in a patient with a history of allergic reactions during anesthesia, whenever possible, to avoid recurrence of anaphylaxis. Although medical staff are likely to notice abnormal vital signs because of complete monitoring during anesthesia, surgical drapes make it difficult to notice the appearance of skin symptoms. Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia.Grade of recommendations and levels of evidence Anaphylaxis is a relatively rare condition with few controlled trials, and thus a so-called evidence-based scrutiny is difficult. Therefore, rather than showing evidence levels and indicating the level of recommendation, this practical guideline only describes the results of research available to date. The JSA will continue to investigate anaphylaxis during anesthesia, and the results may lead to an amendment of this practical guideline.

Sugammadex and rocuronium-induced anaphylaxis

Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.

[Usefulness of ultrasound sonography in performing posterior sacroiliac ligament injection in elderly patients]

BACKGROUND

The sacroiliac joint (SIJ) is recognized as a potential source for low back pain especially in elderly people. Previous studies indicated that in patients with SIJ pain, posterior sacroiliac ligament injections are more effective than intra articular injections. The aim of this study was to assess usefulness of ultrasound sonography (US) in performing posterior sacroiliac ligament injection.

METHODS

We examined SIJ and ligaments, and injected local anesthetics using ultrasonography. US guided needle insertions were performed. We also examined the cadevar of a 74-year-old woman to examine SIJ anatomy.

RESULTS

US was performed in 61 male and 97 female outpatients (N = 158) with a mean age of 72.8 ± 10.9. US examination of the SIJ is difficult to perform because of its complex anatomy, and wide range of normal variations, and relative inaccessibility by surface scanning. The long posterior sacroiliac ligament (LPSL) is visualized as a hyper echoic laminated linear structure. We were able to confirm needle placement and area affected by local anesthetics.

CONCLUSIONS

Our study suggests that US can be useful in performing posterior sacroiliac ligament injections. Sufficient anatomical knowledge and extensive US experience are essential in performing these injections.

[Effect of the sacroiliac ligament block on intractable low back pain in elderly patients]

BACKGROUND

Lumbar spine disease in the elderly people is complicated by a variety of pathophysiology in the spine and the cause of the pain is unclear. Diagnosis of pain may be difficult in patients with pain in the thigh and groin area. Sacroiliac joint is supporting the trunk and movable joint. We examined the effect of the sacroiliac joint block for intractable low back pain.

METHODS

Retrospectively we examined the duration of disease in patients with hip and leg pain visiting the hospital for eight months, and we questioned the site of pain awareness. Newton test, Gaenslen test, Patrick test and Fadire test were carried out for sacroiliac joint pain in patients with at least one positive finding. When performing sacroiliac ligaments block local anesthetics was injected to check the position of the dorsal sacroiliac ligaments under ultrasonic echo whenever possible. The block is performed with the patients prone at a point one finger from the posterior superior iliac spine level at an angle of 30-45 degrees downward toward the outside. Injecting the drugs penetrating the ligament continued to give a feel slightly outward to avoid the iliac Cattelan 23 G needle. We confirmed pain assessment NRS at 11 (0-10), and the improvement of pain was assessed with the change of the NRS on the next return.

RESULTS

NRS showed a significant decrease at all points in time before block, their pain decreased gradually. The patients showed NRS improvement of more than 50% of the first block in 15 of 24 patients.

CONCLUSIONS

Block at the posterior sacroiliac ligament region significantly reduced pain for chronic intractable low back pain. The block was shown to be effective as a treatment and for diagnosis.

[Case of pneumonitis caused by Yokukansan]

A 74-year-old man was admitted to our hospital complaining of severe neck pain and general fatigue. He had been undergoing treatment for post-operative neck pain at the out-patient clinic of our hospital, but was now complaining of pain more intense than usual. Chest X-rays revealed diffuse ground glass shadows in bilateral lung fields, and computed tomography revealed diffuse intestinal shadows. A drug lymphocyte stimulation test (DLST) was also performed at that time. Steroid pulse therapy improved the clinical symptoms, hypoxemia and chest X-ray findings. DLST performed again with Yokukansan and Hachimijiogan 133 days after the initial diagnosis of pneumonitis showed Yokukansan was positive. This result showed Yukukansan may be a causative drug for allergic drug-induced pneumonitis. Any drugs including kanpo may be possible to induce allergic pneumonitis.

[Comparison of intraoperative stress hormones release between propofol-remifentanil anesthesia and propofol with epidural anesthesia during gynecological surgery]

BACKGROUND

Remifentanil recently comes to be used for intraoperative analgesia instead of epidural anesthesia in gynecological surgery. It seems to offer the same stability in vital signs, but stress response during remifentanil anesthesia has not been evaluated. Therefore, we compared remifentanil anesthesia with epidural anesthesia regarding stress hormones.

METHODS

Fifty-one patients scheduled for surgery were randomized into two groups (epidural group: E and remifentanil group: R). Anesthesia was maintained with propofol and epidural ropivacaine in E, and with propofol and remifentanil in R. Plasma concentrations of adrenaline, noradrenaline, dopamine (DOA), cortisol, adorenocorticotropic hormone (ACTH), and blood glucose were measured at five points during the perioperative period.

RESULTS

Adrenaline, noradrenaline and blood glucose were not significantly different between the groups at any point. DOA was significantly higher in R than E at skin closure. Cortisol was significantly higher in R than E at three points during operation. ACTH was significantly higher in E than R at skin closure.

CONCLUSIONS

The inhibition of stress hormone secretion during operation was less in R than E. Regarding stress response, total intravenous anesthesia with remifentanil seems to be a proper method, but to have less potency than general anesthesia using epidural block.

[Anaphylactic reaction to epidural block in an outpatient]

A healthy 29-year-old woman received epidural block for severe lumbago in an outpatient clinic. Fifteen minutes after injection of mepivacaine 0.5% with dexamethasone into the epidural space, the patient complained of itching of eyelids followed by generalized pruritus. Hypotension, erythema and generalized urticaria were observed. Initial treatment was with 100% oxygen through face mask, and additional intravenous fluids, followed by administration of adrenaline, chlorpheniramine and dopamine. Cardiac ultrasound examination showed mildly impaired movement of inferior to septal wall. Her plasma histamine level was transiently elevated during the anaphylactic event; however the serum tryptase level was not. Biological assays for confirming the causative agent and cutaneous test were all negative, but clinical symptoms positivity showed nonimmunological anaphylactic reaction to mepivacaine or dexamethasone. This case report confirms the need for systematic allergological investigation in a case of immediate hypersensitivity reaction occurring during nerve block in patients who had even received similar nerve blocks repeatedly. Pain clinician should be aware of the possibility of anaphylactic reactions involving any drug or substance used for an outpatient.

[The direction and the position of epidural catheter tips inserted 5 cm or 7 cm cephalad did not differ]

BACKGROUND

Epidural catheter insertion is a common procedure in gynecological surgeries. At a previous study, we investigated the catheter's direction and position, inserted 7cm cephalad from T12-L1, with postoperative plain X-P using picture archiving communication system (PACS). 74% of the catheters advanced in cephalad direction and 71.4% of the catheter tips stayed within one vertebra from the puncture level. We estimated that the catheters were too long to advance straight. Then, we planned another prospective study to compare the catheter advanced 7 cm or 5 cm regarding its direction and tip position.

METHODS

Fifty-one female patients receiving gynecological surgery were enrolled. Epidural catheters were inserted from T12-L1 intervertebral space in cephalad direction for the length of 5 cm confirmed with postoperative plain X-P using PACS. The catheter's direction, the length, and the position were verified and compared with the result of the previous study.

RESULTS

The catheters going cephalad appeared more frequently among 5 cm group than 7 cm group. Those going caudalad appeared more frequently among 7 cm group than 5 cm group. However, the catheter tip final position and the length from the puncture levels were not significantly different between the groups.

CONCLUSIONS

The direction and the position of epidural catheter inserted 5 cm or 7 cm cephalad did not differ.

[Assessment of the quality of the newly developed rapid oscillometric blood pressure measurement]

BACKGROUND

The purpose of this study is to examine the accuracy of the Fukuda Denshi DS-7000 noninvasive blood pressure measurement device equipped with two cuff deflation mode: a normal mode and quick mode.

METHODS

Twenty-one patients undergoing elective surgery were divided into two groups by using cardio-ankle vascular index (CAVI): no atherosclerotic group and atherosclerotic group. During anesthesia, two modes of blood pressure measurements were examined with the normal mode followed by the quick mode.

RESULTS

All the patients completed the study, resulting in a total of 1034 paired blood pressure measurements. In both no atherosclerotic group and atherosclerotic group, there were statistically significant correlations among systolic, diastolic and mean blood pressure in two modes. This results certified the accuracy of the quick mode measurement.

CONCLUSIONS

The newly developed rapid oscillometric blood pressure measurement can be useful for perioperative management especially in atherosclerotic patients.

[Efficacy of traditional herbal medicine, Yokukansan on patients with neuropathic pain]

BACKGROUND

Neuropathic pain that is the chronic, severe, and intractable pain, interferes with activities of daily living (ADL) and consequently reduces quality of life (QOL). We reported the efficacy of Yokukansan in patients with neuropathic pain, including acute herpetic pain, postherpetic neuralgia, central poststroke pain, post-traumatic spinal cord injury pain, thalamic syndrome, complex regional pain syndrome and symptomatic trigeminal neuralgia. Yokukansan was more effective compared with traditional medicines, such as tricyclic antidepressants, carbamazepine, gabapentin, and opioids etc., which are recommended to treat neuropathic pain. Recently, effects of Yokukansan is reported on the behavioral and psychological symptoms of dementia (BPSD) in elderly patients with dementia. Repeated administration of Yokukansan decreases expression of 5-hydroxytryptamine (5-HT) 2A receptors in the prefrontal cortex in mice, and Yokukansan also protects destruction of myelin sheaths in rats with thiamine deficient-induced encephalopathy. Mechanism of effectiveness of Yokukansan on neuropathic pain has not been established; however, efficacy of Yokukansan on neuropathic pain has been shown clinically.

CONCLUSIONS

As far as we know, this is the first report that Yokukansan was effective on neuropathic pain. Yokukansan without serious adverse reactions may be a possible medicine for treatment of neuropathic pain in future.

[Confirmation of the position of the epidural catheter regarding its intended direction and location for lumbar epidural block]

BACKGROUND

Epidural catheter insertion is a common procedure for gynecological surgeries. Epidural puncture is usually performed according to the anatomical landmarks without radiographic means. The aim of his study was to confirm the actual level of puncture, and the distance as well as the direction of epidural catheters threaded.

METHODS

Seventy-seven female patients receiving epidural anesthesia were enrolled. Epidural catheter was inserted from T12-L1 intervertebral space in cephalad direction for the length of 7 cm. The catheter was confirmed with postoperative plain X-P using picture archiving communication system. The intended direction and length were compared with the actual data. In addition, we retrospectively analyzed the factors including the performers (resident vs. specialist), the approaches of puncture (median vs. paramedian), and patient physical factors (age, height, body weight, and BMI).

RESULTS

Of the catheters 54.6% was inserted from T12-L1, and 74% of them were advanced in cephalad direction. Of the tip of the catheter 71.4% stayed within one vertebra from the puncture level. The puncture accuracy, the frequency of catheter threaded over one vertebra, and the frequency of catheters threaded in cephalad direction did not differ significantly among performers, approaches and patients physical factors.

CONCLUSIONS

Only 11.7% of the catheters were actually inserted from T12-L1 and advanced in cephalad direction over one vertebra as we had intended.

[Retrospective evaluation of optimal doses of fentanyl by patient-controlled epidural analgesia in management of postoperative pain after gynecological surgery in the elderly]

BACKGROUND

Patient controlled epidural analgesia (PCEA) is a useful method in alleviation of postoperative pain; however, PCEA sometimes provided inadequate pain relief in the elderly. Therefore, we investigated optimal doses of fentanyl by PCEA in management of postoperative pain after gynecological surgery in the elderly.

METHODS

We investigated the pain at rest using 100 mm visual analogue scale (VAS) on the 1st day and 2nd day after the operations. Patients were divided into two groups ; one was well-controlled group (WC group, VAS < 20 mm) and the other was poorly-controlled group (PC group, VAS > or =20 mm). In two groups, we retrospectively compared doses of fentanyl in PCEA, number of demand-PCEA, postoperative nausea as well as vomiting, and delirium during 48 hrs after the operations.

RESULTS

The mean age in WC group was significantly higher than that in PC group. The total dosage of epidural fentanyl did not differ significantly between the groups. In WC group fentanyl of 0.172 microg x kg(-1) hr(-1) was given, and fentanyl 0.197 microg x kg(-1) x hr(-1) in PC group.

CONCLUSIONS

We found that fentanyl 0.172 microg x kg(-1) x 1 hr(-1) by PCEA was the most appropriate dose for alleviation of postoperative pain after gynecological surgery in the elderly.

[Yokuininto improves treatment resistant burning pain in legs]

Yokuininto was effective in treating burning pain in both lower legs of a 58-year-old woman. She felt her lower legs feverish: however, no neurological deficit or abnormal finding in angiography was found. The burning pain was increased by cold and decreased by warm, but was alleviated by epidural block with local anesthetics. After 2-week medication of Yokuininto, burning pain was reduced to 20 to 30% and fever in legs disappeared. Yokuininto has been used for chronic pain in muscle and joint accompanied by swelling or local fever. This patient had no joint pain or swelling, but her burning pain was considered to have resulted from some abnormality in blood circulation due to disorder in discharge of water in the body.

[Effective treatment of acute pain and related symptoms in elderly with herpes zoster]

BACKGROUND

The incidence of herpes zoster increases with age. Immediate pain relief is required for prevention of postherpetic neuralgia (PHN) and also its related symptoms that worsen the general condition because acute herpetic pain often interferes with sleep, mood, and general activities in elderly patients. Nerve block is useful to relief acute pain and recommended for prevention of PHN. Tricyclic antidepressant drugs have antinoticeptive effect in acute pain in experimental models, in addition to its antidepressant effect.

METHODS

Forty elderly patients with herpes zoster within 3 months after the onset underwent nerve blocks and received tricyclic antidepressant drugs. We assessed the effect of treatments and adverse effects.

RESULTS

No significant adverse effects were found in elderly patients who had received nerve blocks and/or tricyclic antidepressant drugs. Alleviation of acute pain was obtained in more than 80% of patients, and in all patients depressive state and/or disturbance of the general condition were significantly improved.

CONCLUSIONS

With careful technique and assessment of patients, both nerve block and tricyclic antidepressant drugs were beneficial and safe treatments in elderly patients with herpes zoster.

Addition of 0.1% bupivacaine to buprenorphine and droperidol in patient-controlled epidural analgesia improved postoperative pain scores on coughing after gynecological surgery

STUDY OBJECTIVE

To compare the analgesic efficacy of additional 0.1% bupivacaine to patient-controlled epidural analgesia (PCEA) using buprenorphine and droperidol after gynecological surgery.

DESIGN

Randomized, double-blinded study.

SETTING

Operating theater and general ward at Jichi Medical School Hospital.

PATIENTS

Thirty patients with American Society of Anesthesiologists physical status I and II scheduled for gynecological surgery.

INTERVENTIONS

Patients received combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia. Patients were assigned to receive PCEA with or without 0.1% bupivacaine. Group 1 (n = 15) received buprenorphine 20 microg and droperidol 0.1 mg diluted with saline, and group 2 (n = 15) received bupivacaine 2 mg, buprenorphine 20 microg, and droperidol 0.1 mg diluted with saline (0.1% bupivacaine solution) in a bolus dose of the PCEA, respectively. No background epidural infusion was used.

MEASUREMENTS

Visual analog pain scale (VAPS) scores at rest and on coughing, and cumulative frequency of self-administrated analgesic solution in PCEA were recorded at 24 and 48 hours postoperatively.

MAIN RESULTS

There were no significant differences noted between the groups in VAPS scores at rest or in cumulative volumes of PCEA solution in 24 or 48 hours postoperatively. Median VAPS scores on coughing in group 2 were significantly lower than those values in group 1 at 24 hours (36 vs 65 mm, P < .001) and 48 hours (32 vs 54 mm, P = .036) postoperatively.

CONCLUSIONS

Addition of 0.1% bupivacaine to PCEA using buprenorphine and droperidol provides better analgesia on coughing after gynecological surgery.

VASOPRESSIN MAY BE USEFUL IN THE TREATMENT OF SYSTEMIC ANAPHYLAXIS IN RABBITS

Recent studies demonstrate that vasopressin is useful when treating hemorrhagic and septic shock. The effect of vasopressin on systemic anaphylaxis has not been investigated except in clinical case reports. Vasopressin increases blood pressure because of vasoconstriction through the V1 receptor. Thus, we evaluated the effect of vasopressin on circulatory depression and bronchoconstriction provoked by systemic anaphylaxis and survival rates in rabbits. In the first set of experiments, 15 nonsensitized rabbits received normal saline (control) and vasopressin at 0.8 or 0.08 U/kg. In the second set, 40 sensitized rabbits received horse serum to induce anaphylaxis, and then received the same drugs as in the first set. In the first set, mean arterial pressure (MAP) in vasopressin groups increased by 18% to 24% compared with the control. Vasopressin at 0.8 U/kg decreased MAP insignificantly before the increases of MAP occurred. In the second set, vasopressin at 0.08 U/kg improved the survival rate. At 45 min after antigen challenge, 69% of the rabbits that received vasopressin at 0.08 U/kg were alive, whereas 29% of the control rabbits and 23% of the rabbits that received vasopressin at 0.8 U/kg were alive. Vasopressin increased MAP by 36% to 109% compared with the control within 5 min, however, at 2 min, vasopressin at 0.8 U/kg had no effect on MAP. Pulmonary dynamics were similar. In conclusion, vasopressin at 0.08 U/kg improved survival rates and severe hypotension provoked by systemic anaphylaxis, suggesting that this agent may be useful in the treatment of systemic anaphylaxis.

Hypotension associated with systemic aggregated anaphylaxis is not attenuated by a selective endothelin-A receptor antagonist, BQ 610, in rabbits in vivo

PURPOSE

The present study was done to investigate the role of endothelin-1 (ET-1) in hypotension and bronchospasm provoked by anaphylaxis in rabbits in vivo.

METHODS

Forty-five rabbits sensitized to horse serum were randomly allocated to five groups: Group 1 (n = 10) received 0.5 nmol x kg(-1) of ET-1; Group 2 (n = 10) received 0.5 nmol x kg(-1) of ET-1 and 200 nmol x kg(-1) of a selective ETA receptor antagonist, BQ 610, without anaphylaxis; Group 3 (n = 5) received 200nmol x kg(-1) of BQ 610 alone without anaphylaxis, Group 4 (n = 10) received normal saline alone before being antigen challenged to induce anaphylaxis; Group 5 (n = 10) received 200 nmol x kg(-1) of BQ 610 before antigen challenge.

RESULTS

Mean arterial pressure (MAP) values were significantly different between Groups 1 and 2. Heart rate (HR), central venous pressure (CVP), dynamic pulmonary compliance (C(dyn)), and pulmonary airway resistance (R(L)) did not differ significantly between Groups 1 and 2. MAP values were significantly decreased compared with baseline in both Groups 4 and 5; however, the values were not significantly different between two groups. CVP values were significantly different between Groups 4 and 5 only at the 15-min time point following antigen challenge. HR, R(L), and C(dyn) values were not significantly different between Groups 4 and 5, nor were the survival rates.

CONCLUSION

BQ 610 does not improve hypotension or survival rates in systemic aggregated anaphylactic rabbits in vivo, implying that circulating ET-1 may not play an important role in anaphylaxis, although direct proof of production of circulating ET-1 or activation of ETA receptors is lacking in this study.

An anaphylactic reaction to blood supplied from patient's mother

We present the case of a 4-year-old girl who developed anaphylactic shock during general anesthesia. Symptoms appeared 80 min into the operation and may have been an immediate allergic reaction to the transfused blood supplied from the child's mother based on the clinical signs, the decrease of components of complements and the elevated concentrations of histamine and tryptase. The blood type was the same and antibody screening test and crossmatch was negative. The blood was irradiated and we used a white cell-reduction filter. This patient possibly has antibodies to her mother's plasma and this type of reaction cannot be prevented by these routine methods. It is reported that the risk of transfusion associated graft-vs.-host disease is high when a patient receives blood from a closely related donor. However, there are, no reports of anaphylactic reactions to blood supplied from mother to child. We suggest that there is a potential for anaphylactic reaction as well as transfusion associated graft-vs.-host disease when a child patient receives blood from the mother.

[Diphenhydramine is useful in a parturient with hypersensitivity to local anesthetics to manage her delivery]

We did an obstetric management of a parturient, aged 32 years, with a history of local anesthetic hypersensitivity. The results of histamine release test, and cellular antigen stimulation test with lidocaine, mepivacaine, bupivacaine and preservative-free lidocaine during her pregnancy showed that all local anesthetics studied were positive. We used diphenhydramine as an alternative local anesthetic for episiotomy to the parturient during the delivery. Infiltration with diphenhydramine provided adequate analgesia without noticeable adverse reaction. One month after the delivery, we performed provocative challenge test with local anesthetics, and confirmed she had positive tests to lidocaine, mepivacaine and preservative-free lidocaine, and negative test to bupivacaine. Diphenhydramine is an adequate alternative of local anesthetics in patients with history of hypersensitivity to local anesthetics.

Comparison of patient-controlled epidural analgesia with and without night-time infusion following gastrectomy

To assess the analgesic efficacy and side effects of a supplemental night-time infusion in patient-controlled epidural analgesia (PCEA) after gastrectomy, we carried out a randomized, double-blind study. The number of requests were lower (P<0.005) in the PCEA plus night-time infusion group than in the PCEA alone group during the postoperative nights. Patients who had a PCEA plus night-time continuous infusion, slept with fewer interruptions than those who had only the PCEA. VAS pain scores on coughing were significantly lower (P<0.05) in the PCEA plus infusion group than in the PCEA alone group during the night following postoperative day 1. In conclusion, a night-time infusion in PCEA following gastrectomy decreases the incidence of postoperative pain, provides a better sleep pattern, and reduces the degree of the pain associated with coughing during the night.

[Relief of subacute herpetic pain and postherpetic neuralgia with repeated application of 10% lidocaine cream]

Analgesic efficacy of repeated application of a lidocaine cream formula was investigated in herpes zoster patients with subacute pain with no further improvement after continued treatment since their acute stage (S-HZ group, n = 23), and in patients to whom past treatments had not provided adequate pain relief (PHN group, n = 28). In both groups, visual analog scale (VAS) values decreased significantly from their corresponding values before the present treatment with few cases of side effects and complete disappearances of the pain in 21.6% of all the patients. The results indicate that the repeated application of the lidocaine cream is a safe and effective treatment method. Significantly higher effectiveness was achieved in the S-HZ group in terms of the difference in the VAS values between before and after the treatment, effectiveness in improving the activities of daily life, and overall efficacy evaluation.

An isoenzyme-selective inhibitor of phosphodiesterase 4 and 1, KF19514, may be useful in the treatment of systemic anaphylaxis: an in vivo study in rabbits

The present study was conducted to determine whether an inhibitor of phosphodiesterases 4 and 1, KF19514, is useful in the treatment of systemic anaphylaxis in fentanyl-anesthetized rabbits. Eighty-two rabbits were randomly allocated to 7 groups. Groups I-1 (0.01 mg x kg(-1)), I-2 (0.1 mg x kg(-1)), and I-3 (1 mg x kg(-1)) received KF19514 10 minutes before antigen challenge, with Group II serving as control. Group IV and Group V received KF19514 and aminophylline 1 minutes after antigen challenge, respectively, with Group III serving as control. The survival rate was higher in Groups I than in Group II, rates were similar in Groups I-1, I-2, and I-3. The survival rate was also higher in Group IV than in Group III. Pulmonary resistance (R(L)) was significantly lower in Groups I-2 and I-3 than in Group II. Dynamic pulmonary compliance (C(dyn)) was significantly higher in Group I-3 than in Group II. Heart rate and central venous pressure were similar in Groups I and II. In Groups III, IV, and V, heart rate and mean arterial pressure were comparable, but central venous pressure in Group IV was significantly lower than in Group V. In conclusion, the administration of KF19514, an inhibitor of PDEs 4 and 1, to rabbits either before or after antigen challenge improved bronchoconstriction provoked by systemic anaphylaxis with minimal concomitant cardiovascular side effects compared with aminophylline, suggesting that this agent may be useful in the treatment of systemic anaphylaxis.

[Comparison of five patient-controlled analgesia drug delivery devices]

We report the performance and our impression of five patient-controlled analgesia (PCA) drug delivery devices commercially available; Atom PCA Pump 500, AP-II, Deltec CADD-PCA 5800, Sabratek 6060 and Verifuse. Each of these devices has unique features for PCA. However, these devices still leave some room for improvement. Especially, we hope that future devices will be lighter to carry and use dry batteries more economically. In order to use these devices effectively for the management of pain, it is important to understand their characteristics.

[Appropriate duration of postoperative pain relief by continuous epidural infusion in patients receiving hysterectomy or ovarian tumor resection: comparison of three methods]

We evaluated effects of continuous epidural infusion on postoperative pain, and frequency of its side effects. Patients who had undergone elective gynecological operations were randomly allocated into three groups by difference in duration of indwelling of epidural catheters: patients receiving epidural block only during operations (group M); patients receiving continuous epidural infusion for 2 postoperative days (group B 2); patients receiving continuous epidural infusion for 4 postoperative days (group B 4). In group M, morphine 3 mg and 1 or 2% lidocaine 5-7 ml were given before the start of operation, and epidural catheter was removed after the end of operations. In group B 2 and B 4, morphine 2 mg and 1 or 2% lidocaine 5-7 ml were given before the start of operation, and morphine 8 mg in 50 ml of 0.25% bupivacaine was continuously infused at a rate of 0.5-1 ml.hr-1. We evaluated visual analogue scale (VAS) at rest and moving, and verbal descriptor pain score. Frequencies of supplementary analgesics, vomiting and nausea, residual urine volume after removal of bladder catheter, and timing to initiation of bowel movement after operation were also recorded. VAS at rest was significantly higher in group M than in groups B 2 and B 4 for 2 postoperative days, but no significant difference was seen between the three groups for three postoperative days. VAS at moving did not differ between the 3 groups. Verbal descriptor pain score was significantly higher in group M than in groups B 2 and B 4 for 3 postoperative days, but it was not different between groups B 2 and B 4. In group B 2, patients complained increased abdominal pain after removing catheters. Frequencies of supplementary analgesics were 3.7, 0.6 and 0.4 times in group M, B 2, B 4, respectively. Times to initiation of bowel movement after operation were 39.8, 46.5 and 61.7 hrs in group M, B 2, and B 4, respectively, and most patients in group B 4 felt uncomfortable. These results suggest that continuous epidural analgesia for 2 postoperative days is appropriate, but the duration should be determined according to patient's conditions and complications.

Systemic hypotensive response to protamine following chronic inhibition of nitric oxide synthase in rats

PURPOSE

The aims of the present studies were to determine whether the systemic hypotensive response to protamine was modified in rats pre-treated for two weeks with the nitric oxide synthase inhibitor, NG-nitro-L-arginine-methyl ester (L-NAME), and to evaluate the inhibitory effect of heparin on the systemic hypotensive response to protamine in vivo.

METHODS

Male rats were randomly assigned into four groups. Normal saline 12 microliters.day-1, D-NAME (an inactive enantiomer of L-NAME), 10 mg.kg-1, L-NAME, 1 or 10 mg.kg-1.day-1 i.p. was administered for two weeks and the haemodynamic changes were measured after protamine administration. In another experiment, male rats were assigned to two groups. In one, the heparin group, protamine was administered after heparin had been administered and in the other, protamine group, protamine alone was administered.

RESULTS

L-NAME inhibited the decrease in systemic arterial pressure after protamine administration (P < 0.05), but D-NAME had no effect. Also, heparin reduced the decrease in systemic arterial pressure after protamine (P < 0.05).

CONCLUSION

Nitric oxide is mainly responsible for mediation of the systemic hypotensive response to protamine which is also reduced by heparin.

Comparison of patient-controlled epidural analgesia with and without background infusion after gastrectomy

To assess the analgesic efficacy and side effects of concurrent infusion in patient-controlled epidural analgesia (PCEA) after upper abdominal surgery, 40 patients undergoing elective gastrectomy under general anesthesia were allocated to two groups in this randomized, double-blind study: one received a 2.5-mL incremental bolus in a solution of 0.2% bupivacaine and 10 microg/mL fentanyl, and the other received the same bolus dose plus a 2.5-mL/h infusion of the same solution. The number of demands was smaller (P < 0.001) in the PCEA plus infusion group than in the PCEA alone group during the 48-h postoperative period. The average hourly fentanyl and bupivacaine doses were larger (P < 0.0001) in the PCEA plus infusion group than in the PCEA alone group. Visual analog scale pain scores on coughing in the PCEA plus infusion group were lower than in the PCEA alone group (P < 0.05). There was a greater incidence of pruritus in the PCEA plus infusion group (P < 0.05), but no serious side effects were observed in either group. In conclusion, a background infusion in PCEA with a mixture of fentanyl and bupivacaine decreases the incidence of postoperative pain and reduces the degree of pain associated with coughing without serious side effects after gastrectomy.

IMPLICATIONS

A background infusion in patient-controlled epidural analgesia with a mixture of fentanyl and bupivacaine decreased the incidence of postoperative pain and reduced the degree of the pain associated with coughing without serious side effects in this randomized, double-blind study after gastrectomy.

Dose-related cardiovascular effects of amrinone and epinephrine in reversing bupivacaine-induced cardiovascular depression

BACKGROUND

To ascertain the efficacy of amrinone and epinephrine in reversing bupivacaine-induced cardiovascular depression, we investigated the time course of recovery of cardiac function with 3 doses of both agents after bupivacaine administration.

METHODS

In sevoflurane-anaesthetized dogs, bupivacaine was infused intravenously at 1 mg.kg-1.min-1 until mean arterial pressure fell to 60 mmHg or less. The 3 doses of amrinone (1, 2, and 4 mg.kg-1) or the 3 doses of epinephrine (2, 5, and 10 micrograms.kg-1) were administered as a bolus in randomized order in each dog.

RESULTS

Amrinone improved maximum left ventricular dP/dt, a time constant of left ventricular isovolemic relaxation and cardiac index persistently and dose-relatedly. Amrinone increased heart rate and decreased left ventricular end-diastolic pressure and systemic vascular resistance index. Amrinone at 1 and 2 mg.kg-1 significantly increased mean arterial pressure, but amrinone at 4 mg.kg-1 did not. Epinephrine increased mean arterial pressure, maximum left ventricular dP/dt, and systemic vascular resistance dose-relatedly. The duration of action of epinephrine, peaking at 1 min and subsequently decreasing by 10 min after administration, did not differ among the groups. Epinephrine at all doses failed to improve a time constant of left ventricular isovolemic relaxation and cardiac index. ECG evidence of serious ventricular dysrhythmias was seen in 1 out of 6 dogs after administrating each dose of amrinone and in 3, 3 and 5 out of 6 dogs after administrating 2, 5 and 10 micrograms.kg-1 of epinephrine, respectively.

CONCLUSION

Bolus amrinone may have a certain efficacy in reversing bupivacaine-induced cardiovascular depression, and improving cardiac contractility and relaxation dose-relatedly. In contrast to amrinone, bolus epinephrine remains indispensable for resuscitation, causing a rapid, massive, transient and dose-related rise in blood pressure. However, the use of amrinone may be limited predominantly by a decrease in systemic vascular resistance, while the use of epinephrine may be limited predominantly by the generation of serious ventricular dysrhythmias and lack of effectiveness on cardiac index and on cardiac relaxation.

[Tracheal intubation for emergent tracheostomy in a patient complicated with tracheal stenosis]

We report the management of anesthesia for emergent tracheostomy in a patient with severe tracheal stenosis. A 63-year-old male was scheduled for an emergency tracheostomy for severe tracheal stenosis due to the invasion of a thyroid cancer. A preoperative neck CT revealed the tracheal stenosis, extending from 1-2 cm below the vocal cord to the upper end of the sternum. The narrowest caliber was about 7 mm in transverse diameter. Moreover, the cancer was suspected to have a bleeding tendency. General anesthesia with endotracheal intubation was considered necessary to provide an open airway during tracheostomy. Anesthesia was induced with thiopental, and a 6.0 mm endotracheal tube with cuff was successfully introduced with a balloon introducer (AIRGUID E) using suxamethonium. We were able to perform tracheostomy uneventfully.

Platelet-activating factor is a key mediator of pulmonary vasoconstriction and bronchoconstriction after antigen challenge in the perfused sensitized rabbit lung

Exposure of sensitized perfused rabbit lungs to human O-N type erythrocytes leads to pulmonary vasoconstriction and bronchoconstriction. To investigate whether platelet-activating factor (PAF) is a mediator of pulmonary vasoconstrictive and bronchoconstrictive responses after antigen challenge, we administered antigenic erythrocytes after the administration of PAF antagonist (.1 mg/kg; CV6209). Pulmonary arterial and airway pressures significantly increased after antigen challenge in the sensitized rabbit lungs, but not in the nonsensitized rabbit lungs. CV6209 significantly inhibited these pulmonary vasoconstrictive and bronchoconstrictive responses after antigen challenge. We concluded that PAF, at least in part, plays an important role in pulmonary vasoconstriction and bronchoconstriction after antigen challenge in rabbits.

An inhibitor of poly(adenosine 5'-diphosphoribose) synthetase, 3-aminobenzamide, does not improve cardiovascular depression, bronchospasm, or survival associated with systemic anaphylaxis in rabbits in vivo

We investigated whether an inhibitor of poly(adenosine 5'-diphosphoribose) synthetase (PARS) is beneficial in anaphylaxis. Twenty-eight rabbits were randomly allocated to three groups: Group I (control) received .9% NaCl solution 10 min before antigen challenge followed by the infusion of the same solution. Group II (3-aminobenzamide 20 mg.kg-1) received 20 mg.kg-1 of 3-aminobenzamide (a PARS inhibitor) 10 min before antigen challenge followed by the continuous infusion of 20 mg.kg-1 of 3-aminobenzamide. Group III received 40 mg.kg-1 10 min before antigen challenge followed by the continuous infusion of 20 mg.kg-1 of 3-aminobenzamide. Survival were similar between three groups. Heart rate, mean arterial pressure (MAP), central various pressure, and pulmonary resistance did not differ between three groups. Dynamic pulmonary compliance did not differ in the early phase after the antigen challenge; however, it was significantly lower in Group III than in Groups I and II 15 min after the initiation of anaphylaxis. 3-aminobenzamide per se did not affect heart rate, MAP, central venous pressure, pulmonary resistance, or dynamic pulmonary compliance in animals without systemic anaphylaxis. In conclusion, this PARS inhibitor did not improve cardiovascular depression or bronchospasm in the early phase of systemic aggregated anaphylaxis in rabbits in vivo, implying that the pathophysiological changes associated with systemic anaphylaxis may not be related to activation of an energy-consuming DNA repair cycle triggered by PARS.

[Massive bleeding from the ruptured liver and the inferior vena cava controlled with autotransfusion and cerebral ischemia treated with mild hypothermia]

A patient suffered massive bleeding from the ruptured liver and laceration of the inferior vena cava due to traffic accident, and developed hypotension and decreased level of consciousness. The patient was transferred to our hospital for an emergency operation against intra-abdominal massive bleeding. This massive bleeding was controlled with autotransfusion using washing salvaging autotransfusion device (Cell Savor). Suspected brain ischemia was treated with intended mild hypothermia. When blood pressure decreased to 30 mmHg of systolic pressure over 7 minutes during the operation, suggesting the possible brain ischemia, mild hypothermia was maintained at 33.8 degrees C. Total bleeding volume was 16,700 ml, and total transfused volume was 10,700 ml. Of total transfused volume, 4,500 ml was washed salvaged blood using the intraoperative autotransfusion device. No neurological deficit was found during the postoperative course. The patient was discharged uneventfully on the 20th postoperative day. In conclusion, intraoperative autotransfusion with washed salvaged blood is a useful method for treatment of massive bleeding, and mild hypothermia is efficacious for protecting the brain from ischemia resulting from accidental hypotension.

[Intraoperative re-rupture of gastric varix immediately after the start of an operation in a patient with liver cirrhosis]

Gastroesophageal variceal hemorrhage is a rare complication during an operation. We present a case of gastric variceal re-rupture during an emergent operation for devascularization of the gastric veins. The patient was a 72-year old man with liver cirrhosis, who developed gastric variceal hemorrhage on the day of surgery. Sclerotherapy with an endoscope was performed, and the hemorrhage was controlled four hours before entering the operating theater. The induction of anesthesia and tracheal intubation were done with rapid sequence because the patient was regarded as full stomach. Induction was completed successfully. However, gastric varix ruptured immediately after the beginning of the surgery. The hemorrhage into the stomach amounted to 2,165 ml. The patient developed hypotension of 40 mmHg of systolic pressure for 15 minutes. With fluid resuscitation, continuous infusion of dopamine and ligation of varix, the patient recovered from this hypotensive event. No neurological deficit developed postoperatively. Portal hypertension results from increased resistance to portal venous blood flow or increased portal venous blood flow. Therefore, increased intravascular volume may play a significant role in precipitating variceal hemorrhage. In this case, abrupt circulatory change due to inadequate depth of anesthesia may partly cause massive hemorrhage. In conclusion, since potential adverse effects of increased blood volume and hepatic resistance on variceal hemorrhage must be considered during anesthesia, patients with episode of variceal hemorrhage should be treated as full stomach although endoscopic findings before the surgery indicate controlled hemorrhage from varix.

[Premixing lidocaine reduces the incidence and severity of pain on injection of propofol]

The purpose of this study was to confirm the effect of premixed lidocaine for the reduction of pain during injection of propofol in adult patients. We conducted a prospective, randomized, double-blind trial on 106 patients. In the study group (n = 54), lidocaine 40 mg (2 ml of lidocaine 2%) was added to 180 mg of propofol (18 ml). In the control group (n = 52), 2 ml of normal saline was added to 180 mg of propofol. The pain on injection was rated as none, mild, moderate, or severe. Eleven patients (20.4%) in the study group experienced pain compared with 25 (48.1%) in the control group. Thirteen in the control group complained moderate or severe pain compared with only one in the study group. In conclusion, lidocaine 40 mg premixed with 180 mg propofol significantly reduces the incidence and severity of pain associated with propofol injection.

The lumbar extradural structure changes with increasing age

We have examined the extradural space using a flexible extraduroscope in 74 patients undergoing extradural anaesthesia at the L2-3 interspace. Extraduroscopy showed that the extradural space becomes widely patent and the fatty tissue in the extradural space diminishes with increasing age. We postulate that these age-related structural changes may affect the spread of local anaesthetic in the extradural space.

[The spread of subarachnoid hyperbaric dibucaine in the term parturient]

To study the effect of patient's age, height, body mass index (BMI), site of injection, and volume injected on determining the spread of hyperbaric spinal anesthesia in the term parturient, we performed a retrospective analysis on 86 parturients who had received 0.3% hyperbaric dibucaine for cesarean section. All patients received subarachnoid injection of the drug in the left lateral decubitus position on a horizontal operating table. After the drug was injected, the final cephalad level of analgesia to pinprick was measured. Multiple regression analysis revealed that BMI and volume injected had relatively stronger relation with the spread of sensory analgesia, when compared to the others. However, neither of them was a significant determinant of the level of analgesia. In conclusion, patient's age, height, BMI, site of injection and volume injected were not significant determinants of hyperbaric dibucaine spinal anesthesia in the term parturient.

[Prostagrandin E1-induced hypotension well maintains cerebral circulation and carbon dioxide reactivity in non-neurosurgical patients under sevoflurane-anesthesia]

To evaluate the effect of prostagrandin E1 (PGE1)-induced hypotension on cerebral blood flow (CBF) and carbon dioxide (CO2) reactivity of CBF, regional cerebral hemoglobin oxygen saturation (rSo2) was measured in non-neurosurgical patients (n = 10) under sevoflurane-anesthesia using near infrared spectroscopy. PGE1 was infused intravenously to maintain arterial pressure at a level of about 75% of the MAP (hypotensive group) under sevoflurane-anesthesia alone (normotensive group). Ventilation was controlled to adjust PaCO2 to hypocapnia (25-30 mmHg), normocapnia (35-40 mmHg) and hypercapnia (45-50 mmHg) in both normotensive and hypotensive groups. rSo2 during hypotension did not change by hypocapnia and normocapnia, but significantly increased by hypercapnia, compared with rSo2 during normotension. Significant correlations between rSo2 and PaCO2 during both normotensive and hypotensive groups were observed. Slope of the regression line of rSo2 and PaCO2 did not differ between the normotensive and hypotensive groups. When arterial oxygen content and cerebral metabolic rate of oxygen are constant, changes in rSo2 correlate with those of CBF. Therefore, CBF and CO2 reactivity of CBF that indicates autoregulation in response to changes in CO2 during hypotension were maintained as those during normotension. The results show that PGE2-induced hypotension maintains CBF and CO2 reactivity well in non-neurosurgical patients under sevoflurane anesthesia.

[Cesarean section in a morbidly obese parturient under epidural anesthesia]

A 26-yr-old morbidly obese parturient with a body mass index of 62 kg.m-2 underwent elective cesarean section for preeclampsia under epidural anesthesia. The distance between the skin and the epidural space was about 9 cm at the L3-4 interspace via mid approach. Epidural catheter was inserted 5 cm cephalad in the sitting position and a bolus of 17 ml of mepivacaine 1.5% was given in the supine position. The T5 level of analgesia was obtained 10 min later. Forty minutes after the start of the surgery, a female newborn weighing 3,206 g was delivered with an Apgar score 8 at 1 min and 9 at 5 min. Throughout the surgery, sufficient analgesia was obtained and any complications such as severe hypotension and respiratory depression did not develop. Postoperative pain was relieved sufficiently with a continuous epidural infusion of 0.25% bupivacaine at a rate of 0.5 ml.h-1 for two days. Both maternal and neonatal postpartum courses were uneventful. In conclusion, elective cesarean section in a morbidly obese parturient was successfully managed with epidural anesthesia. This indicates that an elective cesarean section under epidural anesthesia reduce the risk of perioperative complications in a morbidly obese parturient.

Failed spinal anaesthesia: cause identified by MRI

PURPOSE

To determine the cause of failed spinal anaesthesia, magnetic resonance images of the lumbar spine were examined.

CLINICAL FUTURES

A 28-yr-old woman, scheduled for closure of a rectal fistula under spinal anaesthesia, hyperbaric tetracaine 12.5 mg injected into the subarachnoid space at L3-4 repeatedly resulted in restricted sacral spread. Magnetic resonance imaging showed that the cylindrical dimension of the lumbar spinal canal was wider than in normal subjects, suggesting a larger volume of CSF within the dural sac below the termination of the cord. The summit of the lumbar convexity was located at L3, which was more cephalad than the L3-4 puncture site.

CONCLUSION

The uncommon anatomical characteristics of the lumbar spinal canal identified by magnetic resonance imaging were considered to be the reason for the restricted sacral spread observed repeatedly in this patient.

Inflammatory changes after extradural anaesthesia may affect the spread of local anaesthetic within the extradural space

We have assessed cephalad spread of analgesia in 491 patients undergoing extradural anaesthesia at the L2-3 or L3-4 interspace. Patients were classified into one of three groups based on the number of previous lumbar extradural anaesthesia procedures: none (group I, n = 339), one (group II, n = 82), and two or more (group III, n = 70). Cephalad spread of analgesia was greater in group I than in groups II and III, regardless of the puncture site. In addition, we examined the extradural space using a flexible extraduroscope in 32 patients who were excluded from the analysis of spread. Extraduroscopy showed the extradural space to be patent in patients with no history of prior lumbar extradural anesthesia, but it was not clearly identified in patients who had received extradural anaesthesia one or more times because of aseptic inflammatory changes, including proliferation of connective tissue, adhesions between the dura mater and the ligamentum flavum, granulation and changes in the ligamentum flavum. Extradural anaesthesia may cause aseptic inflammatory changes in the extradural space which may reduce the spread of analgesia.

Sevoflurane is equivalent to isoflurane for attenuating bupivacaine-induced arrhythmias and seizures in rats

The effects of sevoflurane on bupivacaine toxicity have not been defined. The purpose of this study was to investigate the effects of sevoflurane and isoflurane on bupivacaine-induced arrhythmias and seizures in rats. Thirty-seven Sprague-Dawley rats received bupivacaine intravenously at a constant rate of 2 mg.kg-1.min-1 until both arrhythmias and seizures occurred while electrocardiogram (ECG) and electroencephalogram (EEG) recordings were made. The cumulative doses of bupivacaine inducing arrhythmias and seizures were determined in the presence of 1 minimum alveolar anesthetic concentration (MAC) of sevoflurane (sevoflurane group, n = 14) or isoflurane (isoflurane group, n = 10) and in the absence of anesthetic (control group, n = 13). The cumulative doses of bupivacaine inducing arrhythmias and seizures were larger in the sevoflurane and isoflurane groups than in the control group and were similar in the sevoflurane and isoflurane groups. These results indicate that sevoflurane and isoflurane attenuate bupivacaine-induced arrhythmias and seizures in rats.

[Emergency internal carotid artery ligation using near infrared spectroscopy]

We anesthetized a patient who received an emergency internal carotid artery ligation. Regional cerebral oxygen saturation (rSO2) was measured with near infrared spectroscopy (NIRS) during the whole anesthetic course. The sensor was placed on the left forehead of the patient. Decrease in blood pressure was reflected in the decrease in rSO2. The rSO2 was not altered by internal carotid ligation. However, cerebral infarction in the middle cerebral artery region, the onset of which remained unclear, was revealed postoperatively, regardless of a stable rSO2 during the operation. This monitor may provide useful information regarding the cerebral circulation during the operation in such a case as the present one, but this monitor reflects only the oxygenation of the region on which the sensor was placed. Thus, we should keep in mind the limitation in detecting cerebral dysfunction using NIRS.

[Clinical evaluation of a new programmable syringe infusion pump]

A new programmable syringe infusion pump, Auto Syringe Model AS 40 A, was evaluated for infusion of muscle relaxants, vasodilators and opioids in 4 surgical patients. Every drug mentioned above was easily adjusted according to surgical requirement in these patients. Auto Syringe Model AS40A is light and compact. Its major advantages lie in the mechanisms for delivery of a bolus dose and automated delivery of intermittent doses, automatic rate calculation, and the applicability to various sizes of syringes. Auto Syringe Model AS40A was found to be very useful for intravenous infusion of drugs.

In vivo production of nitric oxide in the canine heart in IgE-mediated anaphylaxis

We investigated the production of nitric oxide (NO) in the canine anaphylactic heart in vivo using an NO-selective electrode. Seven dogs with positive sensitivity to Ascaris Suum were studied. Ascaris Suum was administered into the systemic circulation to induce anaphylaxis, and NO, blood pressure, heart rate, end-diastolic left ventricular pressure, cardiac output, and the maximum rate of rise of left ventricular pressure were monitored for 60 min. The electrode was placed on the surface of the left ventricle adjacent to the interventricular branches of the left coronary artery. NO concentration increased significantly during the period from 2 to 3 min, and tended to increase during the period from 4 to 15 min after antigen challenge, and almost returned to baseline after 20 min. In conclusion, increases in NO in the heart are only observed during the early phase of anaphylaxis.