Differences in perioperative coagulation between Japanese and other ethnic groups undergoing laparoscopic cholecystectomy.

BACKGROUND: Japanese patients experience fewer episodes of postoperative thrombosis than those in certain other countries. To investigate this phenomenon, we measured perioperative coagulation activation markers and conducted thromboelastography (TEG) in 27 Japanese patients undergoing laparoscopic cholecystectomy. METHODS: D-dimer, thrombin-antithrombin complex (TAT), and prothrombin fragment 1+2 (F1+2) were measured as coagulation activation markers. TEG was performed to measure reaction time (R), clot formation time (K), maximum amplitude (MA), and maximum elastance (ME). These measurements were performed before and after the operation and the day after the operation. RESULTS: Coagulation activation markers increased significantly postoperatively. With respect to TEG, MA and ME increased postoperatively. R and K did not change. CONCLUSION: Whereas clotting factor activation sthenia is common in Europe and North America, thrombocyte function sthenia occurs in Japanese patients. This difference may account for the differing incidences of phlebothrombosis in Japanese and white populations.

[A multicenter study of cardiac events and anesthetic management of patients with ischemic heart diseases for noncardiac surgery--a follow-up report].

We have conducted a joint research project to investigate the incidence of ischemic heart disease in patients for noncardiac surgery and to define the risk of perioperative cardiac complications in these patients. From September to November 1997 we had 7288 patients scheduled to undergo noncardiac surgery in the 8 departments of anesthesiology. Of these patients, 228 (3.1%) patients had ischemic heart disease, and 30 of them (13.2%) developed perioperative cardiac events. Critical cardiac events, including perioperative myocardial ischemia and lethal arrhythmia, occurred in 7 of these patients. In our region of Japan, 3-4% of surgical patients tend to develop ischemic heart disease and 3.1% of them demonstrated severe cardiac complications perioperatively. Compared with United States we encounter fewer surgical patients with ischemic heart disease, but the risk of developing perioperative cardiac complications in such patients is almost the same for both countries.

[Multicenter study of cardiac events and anesthetic management of patients with ischemic heart diseases undergoing noncardiac surgery].

We designed a joint research project to investigate the incidence of ischemic heart diseases in patients undergoing noncardiac surgery and to define the risk of perioperative cardiac complications in these patients. Of the 8358 surgical patients in the 8 departments of anesthesiology between March 1997 and June 1997, 328 (3.9%) had ischemic heart diseases. Among the 328 patients, 54 (16.4%) developed perioperative cardiac events, including myocardial infarction (3 patients) and either lethal or potentially dangerous dysrhythmias (51 patients). Preoperative cardiac assessments were performed while the anesthetic techniques including intensive monitoring and perioperative prophylactic therapy were also employed. Patients with ischemic heart diseases received various types of preoperative evaluation to identify the degree of coronary artery disease and to assess the overall cardiac function. The patients were monitored using a multilead electrocardiogram, an arterial line, a central venous catheter, a pulmonary artery catheter, and by transesophageal echocardiography intraoperatively. Therapeutically, isosorbide, nitroglycerin, beta-blockers, calcium channel blockers, and/or nicorandil were administered to prevent perioperative ischemia. So far, no generally accepted management strategies have been established in patients with cardiovascular disorders based on large-scale outcome trials in Japan. Therefore, nationwide large multicenter trials are awaited with interest in order to establish helpful guidelines to improve the perioperative management and to reduce ischemia in cardiac patients undergoing noncardiac surgery.

[Management of severe pain after extended maxillectomy in a patient with carcinoma of the maxillary sinus].

We treated a 65 year-old man with severe facial pain after extended maxillectomy due to carcinoma of maxillar sinus. He had been suffering from pain at rest, on mastication, or at treatment of surgical wound. Various kinds of analgesics had been tried, but his pain did not disappear. At 17 weeks after the operation, he came to our pain clinic. Because his pain was thought to be due to reflex sympathetic dystrophy (RSD), stellate ganglion blocks (SGB) were performed. After 5 administrations of SGB, pain was reduced markedly but the pain at treatment of wound persisted. We thought that persistent pain would need trigeminal nerve block. Then Gasserian ganglion block was performed directly through an open wound after the operation. After the Gasserian ganglion block, the pain was diminished remarkably. He could tolerate procedures for facial prosthesis. Pain control after the operation in this patient was very efficient to improve his quality of life. Serum concentrations of catecholamines, serotonin and substance P were measured. The levels of norepinephrine and serotonin are related to the mechanism of pain as seen in this patient.

[A case of spasticity following spinal cord injury improved by epidural spinal cord stimulation].

Epidural spinal cord stimulation was performed in a patient complaining of spasticity with intractable pain after operation of metastatic spinal tumor. The end of the electrode was positioned along a line extending down the 11th vertebral body. Following confirmation of satisfactory effects during 10 days of trial stimulation, the electrode was permanently implanted. Excellent pain relief (80%) and significant relaxation of spasticity resulted in a medication free period with improved daily activities. Although the treatment of this case resulted in clinical success, the problem concerning the payment of the transmitter remained. We hope that the health insurance system will extend its indications to cover medical fees for the transmitter.

[Cardiovascular changes after intubation and at the time of incision during nitrous oxide-oxygen anesthesia with epidural buprenorphine].

The cardiovascular changes after intubation and at the time of incision under nitrous oxide-oxygen anesthesia with epidural buprenorphine (Bn) were examined. The subjects were 56 patients who underwent abdominal surgery. The patients were divided into two groups in terms of the epidural drugs used, i.e., group I (Bn 0.2 mg + saline 9 ml, n = 31) and group II (Bn 0.2 mg + 1% lidocaine 10 ml, n = 25). The systolic pressure increased significantly (P less than 0.05) to 169 +/- 29 mmHg (mean +/- SD) after intubation and to 162 +/- 28 mmHg after incision in group I, with no decrease in blood pressure during the non-stimulation period. In group II, although there was a significant decrease in blood pressure to 114 +/- 24 mmHg just before incision (P less than 0.05), no elevation of blood pressure was noted after intubation or incision. There was no significant difference between groups I and II with regard to the heart rate and respiratory rate. We were unable to block the cardiovascular reaction after intubation and incision under nitrous oxide-oxygen anesthesia with epidural Bn, requiring local anesthetics or volatile anesthetics. This method, however, is useful for patients in whom a fall of blood pressure should be avoided, e.g., for those with hypovolemia.