A suspected case of rocuronium-sugammadex complex-induced anaphylactic shock after cesarean section.

An anaphylactic reaction during a cesarean section occurs rarely, and rocuronium is thought to be one of the common agents causing perioperative anaphylaxis. Here we report an anaphylactic shock after cesarean section that is suggested to be induced by the rocuronium-sugammadex complex. A 36-year-old primigravida underwent an elective cesarean section under general anesthesia due to placenta previa. While the operation was completed uneventfully, she developed anaphylactic shock following sugammadex administration. She was successfully managed with rapid treatments. Serum tryptase level was significantly elevated. Although sugammadex was first suspected to be the causative agent, the result of intradermal skin tests with sugammadex were negative. Surprisingly, a subsequent intradermal test with undiluted rocuronium caused the patient to fall into a state of shock. Furthermore, a later skin-prick test with pre-mixed rocuronium-sugammadex complex also revealed a strong positive reaction, and a test with only rocuronium showed negative. We finally concluded that the rocuronium-sugammadex complex is the causative agent in this case. To the best of our knowledge, this is the first report suggesting anaphylaxis caused by the rocuronium-sugammadex complex. This case highlights the importance of appropriate examinations to determinate the pathogenesis of anaphylaxis in order to establish risk reduction strategies.

[Preoperative screening of deep venous thrombosis: cutoff value of D-dimer, age and BMI for further examination of DVT by echo-color-Doppler].

BACKGROUND: Pulmonary embolism (PE) is morbid perioperative complication and deep vein thrombosis (DVT) is the most common cause of PE. Echo-color-Doppler examination for DVT is a specific test. But it would not be cost-effective to perform in all preoperative patients. The aim of this study was to determine the cut-off value of age body mass index (BMI) and D-dimer (DD) for further examination (echo) of DVT. METHODS: The age, BMI and DD of patients who had undergone echo-color-Doppler test were retrospectively examined. There were 94 patients scheduled for elective operation under general anesthesia from May 2004 to March 2005 in Himeji Red Cross Hospital. RESULTS: Forty five patients were with DVT and 49 patients were without DVT. There was no significant difference between the two groups in BMI. The cut-off value of age was 39 years and that of D-dimer was 0.8 µg x ml(-1). Discriminant function of DVT and D-dimer age were obtained in the formulae, Z = 0.0047 x (Age)(2) - 0.0565 x (D-D)(2) - 0.0046 (Age) x (DD) - 0.7085 x (Age) +0.546 x (DD) + 26.5674. CONCLUSIONS: We recommend that the patients above the discriminant function curve of DVT should undergo further examination for DVT.

Comparing the acid-suppressive effects of three brands of generic lansoprazole with the original: pharmacokinetic bioequivalence tests do not necessarily guarantee pharmacodynamic equivalence.

Generic drugs contain the same active ingredient as an original drug and have their bioequivalence proved by pharmacokinetic tests. However, few studies have been reported on whether these bioequivalence studies infer pharmacodynamic equivalence. In this study, in eight healthy Helicobacter pylori-negative CYP2C19 extensive metabolizers, we compared the acid-suppressive effects of repeated administration of 15 mg of three brands of generic lansoprazole, Taiproton, Tapizol, and Lansoral, with those of the original lansoprazole, Takepron. Median intragastric pH value for 24-h and % pH > 4 for daytime (08:00-20:00 h) and night-time were significantly higher with any lansoprazole formulation, compared with the control (P < 0.05, Wilcoxon signed-rank test). However, during the daytime, % pH > 4 with Tapizol was significantly lower than the original (P < 0.05). Compared with the original, no significantly larger, but no small range of inter-subject variations were observed in these two parameters for each of the three brands of generic lansoprazole (Bartlett test). Pharmacokinetic bioequivalence tests do not necessarily guarantee pharmacodynamic equivalence.

[Flail chest rescued by mechanicalventilation with early tracheotomy and physiotherapy; report of a case].

A 73-year-old man hit his fore-chest accidentally when he rode his motorcycle. A huge flail chest was observed on his central fore-chest, and multiple fractures of costal cartilage were suspected. He developed pneumonia on the 4th hospital day, and he was intubated and mechanical ventilation was initiated. Because frequent sputum aspiration was necessary and aggressive physiotherapy was desirable, a tracheotomy was performed on the same day of intubation. He recovered from respiratory failure with conservative therapy and the mechanical ventilation was disconnected 13 days later. Tracheotomy in the early phase of respiratory failure with flail chest was very effective and the surgical fixation of flail segment would not be necessary even in the case of 'stove-in chest' like the present case.

Cardiovascular and intravesical pressure responses during natural micturition in conscious rats.

Urinary bladder distension is known to influence the cardiovascular system under a pathophysiological condition such as spinal cord injury, hypertension, and arteriosclerosis. A reflex due to bladder distension and/or contraction is considered as one reason for the cardiovascular disturbance associated with micturition. However, it has remained unknown how much intravesical pressure (IVP) rises during micturition in daily life and to what extent mean arterial blood pressure (MAP) and heart rate (HR) respond at that time. To answer these questions, we attempted to examine the direct changes in IVP, MAP, and HR during natural micturition in freely moving conscious rats. IVP increased from the baseline value of 4 +/- 0.2 mmHg to 14 +/- 0.5 mmHg during natural micturition. Although MAP and HR began to increase before micturition, the increases in MAP and HR became significant 1-4 s before its onset. The peak increases in MAP and HR (7 +/- 0.8 mmHg and 14 +/- 3 beats/min, respectively) were delayed by 2 s from the peak IVP. Following an administration of xylocaine into the urinary bladder, the increases in MAP and HR during micturition were significantly blunted to 5 +/- 2 mmHg and 8 +/- 3 beats/min, although IVP increased the same as it did during micturition without xylocaine. Moreover, the relationship between IVP and MAP or HR during natural micturition resembled that between IVP and the vesico-cardiovascular reflex responses during isovolumic bladder contraction in anesthetized rats. Therefore it is concluded that natural micturition in freely moving conscious rats accompanies the significant cardiovascular responses despite a limited increase in intravesical pressure, to which a reflex from the urinary bladder may substantially contribute.