[Effect of Oral Rehydration Therapy before General Anesthesia on Satisfaction, Stress Response, and Hemodynamics in Surgical Patients for Laparoscopic Colectomy].

BACKGROUND: The recommended intake of clear liquids until 2 hours before surgery is reportedly safe and effective. We investigated whether oral rehydration therapy before surgery had improved satisfaction, stress response, and hemodynamics in patients during perioperative period. METHODS: Patients scheduled to undergo laparoscopic colectomy were enrolled and randomly divided into 2 groups. The oral rehydration therapy (ORT) group (29 cases) was allowed to drink clear liquids until 2 hours before anesthesia induction and the control group (29 cases) fasted from 21 : 00 the night before surgery. All patients entered the operating room at 8: 40. Patient satisfaction was examined after admission to the operating room. The volume and pH of gastric fluid were measured after anesthetic induction. The serum concentrations of cortisol and catecholamine were measured as stress response indicators after anesthetic induction and at the completion of surgery. Intraoperative hemodynamics was also recorded. RESULTS: There were no differences in patient satisfaction, stress response, and hemodynamics between the 2 groups. Intraoperative urine volume was significantly larger in the ORT group. Vomiting and aspiration were not observed in any patient CONCLUSIONS: Oral rehydration therapy until 2 hours before surgery seemed safe but did not improve satisfaction, stress response, and hemodynamics in perioperative patients.

[Bispectral Index Electrodes May Induce Skin Lesions].

Bispectral index (BIS) monitoring has been used since the 1990 s, and many studies on BIS monitoring have demonstrated its usefulness and safety. Currently, BIS monitoring has become indispensable for observation of patients under general anesthesia. However, we observed the development of postoperative skin lesions in 13 patients (11 female and 2 male; age range, 14-76 years) resulting from contact with the BIS electrodes between May 2012 and April 2013. None of the patients had a history of allergies or skin diseases prior to surgery. During the surgery, nine patients were placed in the supine position and four in the prone position. The duration of anesthesia ranged from 2 hr 7 min to 13 hr. The overall incidence of skin lesions was approximately 0.27% (13/4,900), and that in patients in the prone position was 3.1% (4/129). The skin lesions resolved within 1 week without scaring following the application of a steroid-containing ointment. Although the occurrence of such skin complications is rare, some patients may experience postoperative anxiety because skin lesions caused by BIS electrodes are noticeable. Therefore, both the usefulness of BIS monitoring and the potential skin complications should be explained to patients preoperatively prior to obtaining patient consent.

[Case of brain death liver transplantation suspended because of respiratory failure after admission to the operating room].

We experienced a case in which brain death liver transplantation was suspended after admission to the operating room because the impaired oxygenation was aggravated. A 32-year-old man (weight 70 kg, height 164 cm) who had previously undergone living donor liver transplantation for Budd-Chiari syndrome developed hepatic failure 11 months after the transplantation and was enrolled in the waiting list for brain death liver transplantation. Mechanical ventilation and blood purification therapy were performed in the intensive care unit because he was in coma and his respiratory function had gradually worsened. A brain-dead donor was identified 21 days after enrollment. The patient was transported to the operating room when the donor liver arrived at our hospital. However, the surgery was suspended because his respiratory function deteriorated further after induction of general anesthesia. A patient enrolled in the brain death transplantation list often has to wait long for a donor organ. Anesthesiologists should actively participate in the preoperative management and evaluation of a patient's general status during the waiting period.

[Cardioversion for paroxysmal supraventricular tachycardia during lung surgery in a patient with concealed Wolff-Parkinson-White syndrome].

We report a case of paroxysmal supraventricular tachycardia (PSVT) that occurred during video-assisted thoracoscopic (VATS) lobectomy in a patient with concealed Wolff-Parkinson-White (WPW) syndrome. A 59-year-old man with lung cancer was scheduled for VATS lobectomy under general anesthesia. After inserting a thoracic epidural catheter, general anesthesia was induced with intravenous administration of propofol. Anesthesia was maintained with inhalation of desfurane in an air/oxygen mixture and intravenous infusion of remifentanil. Recurrent PSVT occurred three times, and the last episode of PSVT continued for 50 minutes regardless of administration of antiarrhythmic drugs. Synchronized electric shock via adhesive electrode pads on the patient's chest successfully converted PSVT back to normal sinus rhythm. The remaining course and postoperative period were uneventful. An electrophysiological study performed after hospital discharge detected concealed WPW syndrome, which had contributed to the development of atrioventricular reciprocating tachycardia. Concealed WPW syndrome is a rare, but critical complication that could possibly cause lethal atrial tachyarrhythmias during the perioperative period. In the present case, cardioversion using adhesive electrode pads briefly terminated PSVT in a patient with concealed WPW syndrome.

[Spinal anesthesia for cesarean section in a patient with multiple sclerosis].

Spinal anesthesia is thought to be contraindicated for patients with multiple sclerosis (MS). We describe the case of a patient with MS who was administered spinal anesthesia for cesarean section. A 29-year-old woman (weight 55.8 kg, height 154 cm) with MS underwent an urgent cesarean section in the 39th week of her pregnancy for fetal malpresentation. Although the patient had experienced repeated relapses of MS thrice since she was 19, she had remained in remission since the age of 27, and did not have significant neurological disability. A 27 G needle (pencil type) was used for arachnoid puncture, and 0.5% hyperbaric bupivacaine (2.0 ml) was administered to the subarachnoid space at the L3-4 interspace. After confirming that the sensory blockade after spinal anesthesia had spread to T4, cesarean section was performed. For the subsequent 19 months, no remission of MS was recognized. Thus, spinal anesthesia does not seem to be contraindicated for patients with MS in remission state.

[Anesthetic management for laparoscopic sigmoidectomy in a patient with impaired ventricular function caused by cardiac sarcoidosis].

It has been demonstrated that laparoscopic surgery can reduce surgical trauma and postoperative pain, allowing earlier recovery and hospital discharge. However, because patients with severe cardiac depression may not tolerate the adverse respiratory and cardiovascular effects of pneumoperitoneum with a head-up or head-down tilt position, laparoscopic surgery has been avoided in these patients. The present case with low ventricular function (ejection fraction=23-27%) due to cardiac sarcoidosis could successfully undergo laparoscopic sigmoidectomy by using pulmonary artery catheterization. Therefore, laparoscopic surgery can be performed in patients with cardiac dysfunction if the cardiopulmonary responses caused by pneumoperitoneum with a head-up or head-down tilt are sufficiently considered and adverse hemodynamic responses appropriately detected and treated through invasive monitoring techniques such as pulmonary artery catheterization and/or transesophageal echocardiography.

[Anesthetic management for a patient with amyotrophic lateral sclerosis; the neuromuscular monitoring was useful to determine appropriate dosages of rocuronium].

We experienced an anesthetic management with rocuronium and neurostimulator for a surgical patient with amyotrophic lateral sclerosis. A 61-year-old man was scheduled for intrathecal baclofen pump implantation as treatment for his spasticity under general anesthesia. After oxygenation and totally intravenous induction with propofol and remifentanil, we administered 10 mg of rocuronium repeatedly monitoring with neurostimulator. When dosage of rocuronium reached 20 mg, train-of-four count reached 1 and his trachea was intubated without coughing or moving. Anesthesia was maintained intravenously. Train-of-four ratio recovered to 95%, 22 minutes after the first administration of rocuronium. Operation was accomplished uneventfully with no additional rocuronium. Bispectral index value recovered to 98 and the patient awoke and breathed spontaneously 19 minutes after termination of administration of anesthetic agents. We could confirm his stable and adequate respiration and trachea was extubated without reversal of rocuronium. In the postanesthesia care unit, he showed no discomfort and was returned to the ward. His symptoms did not deteriorate postoperatively and he was discharged on the 36th postoperative day.

[Remifentanil increases urine output in patients undergoing laparoscopic colectomy].

BACKGROUND: It has been reported that laparoscopic surgery increases stress response such as oliguria. We investigated whether anesthetic methods affect urine output during anesthesia in patients undergoing laparoscopic colectomy. METHODS: Urine output during anesthesia was compared retrospectively between general anesthesia with intravenous infusion of remifentanil, without epidural anesthesia and general anesthesia combined with epidural anesthesia, without remifentanil. Patients were excluded if they had renal failure and/or had received diuretics. 331 American Society of Anesthesiologists (ASA) physical status 1-3 patients who had undergone elective laparoscopic colectomy were enrolled in the study (remifentanil group; n = 214, epidural group; n = 117). In addition, remifentanil group was divided into two groups (higher dose group; n = 108, lower dose group; n = 106) with the median value of 0.3 g x kg(-1) x min(-1). RESULTS: Urine output during anesthesia in remifentanil group was significantly higher than epidural group, although the volume of fluid infusion was significantly less in remifentanil group. Furthermore, urine output in higher dose remifentanil group was significantly higher than the lower dose group, while there were no significant differences in the volume of fluid infusion between the two groups. CONCLUSIONS: Adequate remifentanil injection might increase urine output by preventing stress response to laparoscopic colectomy.

The usefulness of near-infrared spectroscopy in the anesthetic management of endovascular aortic aneurysm repair.

Near-infrared spectroscopy (NIRS) may be a useful method for monitoring the regional oxygen saturation (rSO(2)) of the lower extremity during endovascular aortic repair. Eighteen patients with thoracic descending and/or abdominal aortic aneurysm were enrolled in this study. NIRS probes were placed bilaterally on the calves. Muscular rSO(2) (mrSO(2)) was monitored every 30 s throughout the operation. In the leg in which the femoral artery was clamped, mrSO(2) values were selected at 3 or 4 points-just before clamping (control value), 30 min after clamping, 10 min after the first declamping, and 10 min after the second declamping following repair of the femoral artery, if necessary. In all patients, mrSO(2) decreased significantly during clamping, from 64 ± 11 % (mean ± SD) of the control value to 32 ± 15 %. After declamping, mrSO(2) recovered to 69 ± 14 % of the control value in 16 patients. In the 2 other patients, however, mrSO(2) did not recover after the first declamping, because of femoral artery dissection. After additional repair, mrSO(2) recovered quickly to the control value. These data suggested NIRS may objectively and quantitatively reflect oxygenation of the lower extremities, and may indicate an ischemic event that needs additional repair during endovascular aortic repair.

Sterilization effect of UV light on Bacillus spores using TiO(2) films depends on wavelength.

UV light and photocatalysts such as titanium dioxide (TiO(2)) and silver (Ag) are useful for disinfection of water and surfaces. However, the effect of UV wavelength on photocatalytic disinfection of spores is not well understood. Inactivation of Bacillus spores has been examined using different UV wavelengths and TiO(2) or TiO(2)/Ag composite materials. The level of UVA disinfection of Bacillus anthracis and Bacillus brevis vegetative cells increased with the presence of the TiO(2) and Ag photocatalysts, but had little effect on their spores. B. brevis spores were slightly more sensitive to UVB and UVC than the spores of B. atrophaeus. Photocatalytic sterilization against spores was strongest in UVC and UVB and weakest in UVA. The rate of inactivation of Bacillus spores was significantly increased by the presence of TiO(2), but was not markedly different from that induced by the presence of Ag. Therefore, TiO(2)/Ag plus UVA can be used for the sterilization of vegetative cells, while TiO(2) and UVC are effective against spores.

Additional effects of silver nanoparticles on bactericidal efficiency depend on calcination temperature and dip-coating speed.

There is an increasing interest in the application of photocatalytic properties for disinfection of surfaces, air, and water. Titanium dioxide is widely used as a photocatalyst, and the addition of silver reportedly enhances its bactericidal action. However, the synergy of silver nanoparticles and TiO(2) is not well understood. The photocatalytic elimination of Bacillus atrophaeus was examined under different calcination temperatures, dip-coating speeds, and ratios of TiO(2), SiO(2), and Ag to identify optimal production conditions for the production of TiO(2)- and/or TiO(2)/Ag-coated glass for surface disinfection. Photocatalytic disinfection of pure TiO(2) or TiO(2) plus Ag nanoparticles was dependent primarily on the calcination temperature. The antibacterial activity of TiO(2) films was optimal with a high dip-coating speed and high calcination temperature (600°C). Maximal bacterial inactivation using TiO(2)/Ag-coated glass was also observed following high-speed dip coating but with a low calcination temperature (250°C). Scanning electron microscopy (SEM) showed that the Ag nanoparticles combined together at a high calcination temperature, leading to decreased antibacterial activity of TiO(2)/Ag films due to a smaller surface area of Ag nanoparticles. The presence of Ag enhanced the photocatalytic inactivation rate of TiO(2), producing a more pronounced effect with increasing levels of catalyst loading.

[Anesthetic management for a patient with scoliosis combined with central core disease].

We gave general anesthesia to a patient with scoliosis combined with central core disease (CCD). CCD is a slowly progressive autosomal dominant congenital myopathy. CCD is presented typically in infancy with hypotonia and delay of motor development, characterized by predominantly proximal weakness pronounced in the hip girdle. Orthopedic complications are common with congenital dislocation of the hips, scoliosis and foot deformity. CCD is due to mutations in the skeletal muscle ryanodine receptor (RYR1) gene at chromosome 19q13.1, which is also implicated in the malignant hyperthermia (MH). A patient with CCD is at risk of MH, with an abnormal response to suxamethonium and volatile anesthetics. The anesthetist ought to be aware of the diagnosis of CCD and to plan anesthetic management accordingly, avoiding potentially MH-triggering agents. We used total intravenous anesthesia (TIVA) in this case, and he showed no MH symptoms perioperatively. This report demonstrates that anesthesia in a patient with CCD could be successfully maintained with TIVA.

[Usefulness of human atrial natriuretic peptide (hANP) on perioperative management for liver resection].

BACKGROUND: We investigated whether postoperative renal function was affected by a low central venous pressure (CVP) management induced by restricted fluid administration in order to reduce blood loss during liver resection. In addition, we examined whether the continuous low-dose infusion of human atrial natriuretic peptide (hANP) during operation improved perioperative hemodynamic status and postoperative renal function in surgical patients for hepatectomy who were managed to maintain CVP at a low level. METHODS: The 39 subjects underwent liver resection, and they were randomized to receive 0.025 microg x kg(-1) x min(-1) of hANP (n = 19) or placebo (saline, n = 20) infusion during surgery. Blood samples for measurement of serum concentrations of BUN and creatinine were taken before surgery, at admission to ICU and on postoperative day 1. RESULTS: The mean volume of fluid infusion and urinary output were significantly higher in the hANP group, but there were no differences in the values of BUN and creatinine during perioperative period between the two groups. CONCLUSIONS: A restricted fluid infusion strategy during liver resection did not affect postoperative renal function and the continuous infusion of hANP showed no improvement effects on BUN and creatinine concentrations.

[A case of tension pneumothorax after general anesthesia].

A 72-year-old male patient was scheduled for extirpation of the right kidney and ureter with partial resection of the bladder. Anesthesia was maintained with general and epidural anesthesia. After the end of surgery, he awoke and his spontaneous ventilation seemed to be good. Soon after extubation, he developed cyanosis and circulatory arrest. Immediately cardiopulmonary resuscitation was performed and regular beating of the heart was restored about 6 minutes after cardiac arrest. A chest x-ray showed pneumothorax on right side and he was diagnosed as tension pneumothorax caused by injury of the right diaphragmatic pleura during surgery. Pneumothorax was improved by drainage of the right thoracic cavity, and he was transferred to the intensive care unit. After 4 days of hypothermic therapy, he showed no neurological deficit and recurrence of pneumothorax was not observed. We should be aware of the occurrence of pneumothorax during perioperative period in the patients who underwent surgical procedure in the vicinity of the diaphragm.

[Effects of propofol or sevoflurane on cerebral regional oxygen saturation (rSO2) during one-lung ventilation].

BACKGROUND: The present study was designed to evaluate the alteration of cerebral regional oxygen saturation (rSO2) associated with propofol or sevoflurane during one-lung ventilation (OLV). METHODS: Fifty patients scheduled for a lung lobectomy were randomly assigned to propofol or sevoflurane group. General anesthesia was maintained with propofol (target controlled infusion; 2-3 mcg x ml(-1)) in propofol group (n=25), and sevoflurane (end-tidal concentration 1-2%) in sevoflurane group (n=25), being adjusted to maintain BIS values between 40 and 60. BIS and rSO2 values were continuously monitored. Arterial blood gas analysis was performed as follows: during two-lung ventilation before OLV (baseline), during the first 120 minutes of OLV and at the end of OLV and surgery. RESULTS: During OLV rSO2 was significantly lower than baseline in both groups. The values of rSO2 were not significantly different between the groups at each time. We could not find accurate correlation between rSO2 and other factors monitored. CONCLUSIONS: We conclude OLV leads to the decrease of rSO2, but there is no difference in the alteration of rSO2 between propofol and sevoflurane group. To maintain adequate rSO2, we should consider together in combination with respiratory, circulatory or metabolic index and depth of anesthesia.

[Case of traumatically bleeding shock patient rescued by using an aortic occlusion balloon catheter during surgery].

A 55-year-old (163 cm, 70 kg) man with traumatic intra-abdominal bleeding underwent emergency operation. The patient was in a state of hemorrhagic shock with 82 mmHg of systolic blood pressure (SBP) at hospital arrival. His condition became severer within about 1 hr, and tracheal intubation and mechanical ventilation were consequently started in the ambulatory emergency room. SBP decreased to 60 mmHg when he was transferred to the operating room. Anesthesia was induced with intravenous fentanyl and vecuronium, and was maintained with inhalation of sevoflurane in 50% oxygen. After laparotomy, it was impossible to detect the bleeding source because of a large quantity of hemorrhage. To reduce the blood loss, aortic occlusion balloon catheter (AOBC) was inserted into the upper abdominal aorta via the right femoral artery. Aortic occlusion was performed twice each for twenty minutes. The evelation of SBP and decrease of bleeding dose were secured by aortic occlusion. Thereby the source of bleeding could be detected and surgical procedure could be finished with survival of the patient. The insertion of AOBC for the surgical patient with intra-abdominal hemorrhagic shock may be advantageous for uncontrollable bleeding.

[Changes in cardio-pulmonary function during laparoscopic colectomy and postoperative quality of life--comparison with laparotomy].

BACKGROUND: We investigated whether laparoscopic colectomy would affect the degree of respiratory and circulatory changes during surgery and could improve postoperative quality of life (QOL) as compared with laparotomy. METHODS: Fifty-one patients (ASA 1-3) scheduled for elective colectomy under general anesthesia with epidural anesthesia were enrolled in the study. All patients were divided into two groups (laparoscopic group: n = 33 and laparotomy group: n = 18) by surgical indication. Respiratory functions and hemodynamic changes were measured during surgery. Postoperative complications, pain scores, the time to start of walking and the period of hospital stay were examined. The serum concentrations of inflammatory cytokines (IL-6, IL-1 ra) and KL-6 were measured perioperatively. RESULTS: It was demonstrated that pneumoperitoneum and postural tilt had a bad influence on respiratory functions especially on pulmonary compliance and a-ET(D)co2 in laparoscopic group. The serum concentrations of inflammatory cytokines were significantly lower and the number of rescue for postoperative pain were less in laparoscopic group. The patients in laparoscopic group could begin to walk and leave hospital earlier after surgery. CONCLUSIONS: Severe complication did not occurr in both groups during the perioperative period. Laparoscopic surgery could improve postoperative QOL.

Inhibition of poly (ADP-ribose) synthetase improves pulmonary arterial endothelium-dependent relaxation after ischemic-reperfusion injury of splanchnic artery in rats.

The role of poly (adenosine diphosphate-ribose) synthetase (PARS) in the contractile and relaxant responses of pulmonary arteries injured by ischemia and reperfusion (IR) of splanchnic artery has not been evaluated. We examined these responses by using 3-aminobenzamide, a pharmacological inhibitor of PARS. IR models in rats were induced by clamping the superior mesenteric artery for 60 min, followed by release of the clamp for 60 min. In the 2 treated groups, 5 or 10 mg/kg of 3-aminobenzamide was administered as an IV bolus at 10 min before reperfusion, followed by infusion rates of 5 and 10 mg.kg(-1).h(-1), respectively, during the period of reperfusion (IR + PARS inhibitor 5 and 10 groups). In the vehicle-treated group, 3-aminobenzamide was not given, but IV saline was administered (IR group). In the control group, surgery was performed, but the superior mesenteric artery was not occluded (sham group). The pulmonary arteries were isolated, and effects of drugs were evaluated in vitro. The IR group showed no attenuation of the contractile responses of the pulmonary artery to phenylephrine. The relaxant responses to endothelium-dependent vasodilators, acetylcholine, and A23187 in the IR group were significantly inhibited when compared with the sham group. The reduction in the relaxant response to endothelium-dependent vasodilators was improved in the IR + PARS inhibitor 5 and 10 groups when compared with the IR group. We concluded that IR attenuated the relaxant responses of the pulmonary artery to endothelium-dependent vasodilators and that PARS inhibitors ameliorate the reduction in the relaxant response.