[How to improve positioning of the head--the sniffing position, considered to be suitable for endotracheal intubation].

BACKGROUND: The sniffing position, a combination of flexion of the neck and extension of the head, is considered to be suitable for the performance of endotracheal intubation. To place a patient in this position, anesthesiologists usually put a pillow under a patient's occiput. However, with a regular pillow, the resulting extension of the head tends to be suboptimal. METHODS: In an attempt to improve positioning of the head, we started using "a triangular pillow". The name of this pillow comes from its shape in the sagittal section. A patient's head rests on a slope of the pillow so that it assumes an extended position. RESULTS: In this retrospective study, we compared the triangular pillow and the regular pillow employing the laryngoscopic view grade (Cormack grade) and times for tracheal intubation trial. We found that the triangular pillow group showed lower Cormack grades, compared with the regular pillow group. And in the first attempt, the success rate of the triangular pillow group was higher than that of the regular pillow group. CONCLUSIONS: The triangular pillow improves the laryngoscopic view and facilitates endotracheal intubation by optimizing a patient's head position.

Neutrophil elastase activity in acute lung injury and respiratory distress syndrome.

BACKGROUND AND OBJECTIVE: Neutrophil elastase (NE) may play a key role in the development of acute lung injury (ALI) or ARDS. NE activity (NEA) was measured in patients with ALI treated with a selective NE inhibitor. METHODS: NEA and NE-alpha1-antitrypsin (NE-AT) complex were measured in plasma before, during and after the administration of the selective NE inhibitor, sivelestat, in 32 patients with a diagnosis of ALI or ARDS. NEA index (NEAI) was calculated as NEA/NE-AT. The sequential organ failure assessment (SOFA) score and the ratio PaO(2)/fraction of inspired oxygen (FiO(2)) were measured. RESULTS: NEA and NE-AT was raised in all patients. Sivelestat reduced NEAI and NEA (P < 0.01 for both) but not NE-AT and NEA, and NEAI returned to pretreatment levels. NEA correlated closely with NE-AT before, but not after treatment. No relationship was observed between these indices and SOFA score or PaO(2)/FiO(2) ratio. CONCLUSIONS: Sivelestat reduced NEA and NEAI in patients with ALI or ARDS suggesting NE inhibition. A larger study is needed to determine the relationship of NEA, NE-AT and NEAI with the outcome of ALI/ARDS.

Repeated exposures to hyperbaric air suppress neurite outgrowth in PC12 cells.

Hyperbaric exposure induces lesions of the CNS in scuba divers. Repeated exposures to hyperbaric air at 0.5 MPa for 30 min with short intervals suppressed NGF-stimulated neurite outgrowth, concomitant with a decrease in the protein expression of ERK in PC12 cells. Hyperbaric exposure most likely causes direct lesions of neural cells.

Effects of controlled perioperative antimicrobial prophylaxis on infectious outcomes in pediatric cardiac surgery.

OBJECTIVES: To examine the efficacy of a protocol for the prophylactic use of antimicrobials in pediatric cardiac surgery. DESIGN: Nonrandomized comparison of two groups of patients studied sequentially. SETTING: Pediatric intensive care unit of university hospital. PATIENTS: Infants and children <18 yrs of age who had undergone cardiac surgery. INTERVENTIONS: Limitation of prophylactic antimicrobials to <48 hrs after operation and, in patients at high risk of methicillin-resistant Staphylococcus aureus, strong recommendation to use glycopeptides. MEASUREMENTS AND MAIN RESULTS: No intervention was applied in 189 patients (control group) during the first 21 months, whereas the intervention was applied in 185 patients (intervention group) during the next 18 months. In the intervention group, prophylaxis was recommended to be discontinued <48 hrs postoperatively. As a result, antimicrobials were administered for a median of 4 days (range 2-14) in the intervention group, significantly shorter than 7 days (3-35) in controls. This was associated with a trend toward a lower frequency of postoperative infections, including at the surgical site, and with significantly lower costs of antimicrobial therapy and a significantly lower rate of newly acquired nasal colonization with antibiotic-resistant pathogens in the intervention group (8%) than in controls (17%).Since, in the intervention group, glycopeptides were strongly recommended for patients at high risk of methicillin-resistant S. aureus, the frequency of surgical-site infections (0% vs. 18%) and the frequency of all infections (11% vs. 39%) were significantly lower in the intervention group than in the control group. CONCLUSIONS: Limiting the duration of prophylactic antimicrobials was cost-effective and reduced the risk of acquiring resistant pathogens without increasing the frequency of postoperative infections. The use of glycopeptides in properly selected patients at high risk of methicillin-resistant S. aureus infection can lower the risk of postoperative infections.

[Landiolol prevented myocardial ischemia in a patient with severe aortic stenosis undergoing total gastrectomy].

Gastric cancer was detected in a 71-year-old man with severe aortic stenosis. According to ACC/AHA guidelines, aortic stenosis in the patient was so severe that noncardiac surgery was considered appropriate only after aortic valve replacement. However, due to uncontrollable hemorrhage from gastric cancer, total gastrectomy was urgently required. Surgery was performed under epidural and general anesthesia. Blood pressure and heart rate were stable during anesthetic induction, tracheal intubation and skin incision. Just after peritoneal incision, however, ST decreased significantly following hypertension and sinus tachycardia, which were controllable by deepening of the anesthetic level. This ST depression was dependent on heart rate but not blood pressure. Therefore, in order to control the heart rate and prevent myocardial ischemia, low dose landiolol was infused prophylactically. This agent regulated the heart rate below 85 beats per minute without inducing hypotension and prevented myocardial ischemia during the remaining anesthetic course including extubation and recovery from anesthesia. Although beta blocker is not generally recommended in patients with aortic stenosis, present case suggests that landiolol is effective and useful to prevent cardiac ischemia even in a patient with severe aortic stenosis.

Burn injury enhances brain prostaglandin E2 production through induction of cyclooxygenase-2 and microsomal prostaglandin E synthase in cerebral vascular endothelial cells in rats.

OBJECTIVES: To examine whether peripheral burn injury in rats elevates prostaglandin E2 in the central nervous system and to determine where in the central nervous system enzymes responsible for prostaglandin E2 synthesis are expressed. DESIGN: Prospective controlled animal study. SETTING: University research laboratory. SUBJECTS: Sprague-Dawley rats. INTERVENTIONS: Rats received either approximately 25% full-thickness burn injury or sham treatment. At 36 hrs after the injury, the cerebrospinal fluid was sampled to measure prostaglandin E2, and the brain and the spinal cord were sampled for immunohistochemical detection of cyclooxygenase-2 and microsomal-type prostaglandin E2 synthase, enzymes that are responsible for prostaglandin E2 production. MEASUREMENTS AND MAIN RESULTS: The prostaglandin E2 concentration in the cerebrospinal fluid was significantly elevated in the injured rats, and this elevation was suppressed by a cyclooxygenase-2-specific inhibitor, NS398. Only in the injured rats, cyclooxygenase-2 and microsomal-type prostaglandin E synthase proteins were detected in vascular endothelial cells throughout the central nervous system with no regional difference. A double-immunofluorescence study revealed that cyclooxygenase-2 and microsomal-type prostaglandin E synthase were coexpressed in the perinuclear region of the endothelial cells. CONCLUSIONS: These results indicate that peripheral burn injury induces cyclooxygenase-2 and microsomal-type prostaglandin E synthase in endothelial cells of the central nervous system. These enzymes likely elevate the cerebrospinal fluid concentration of prostaglandin E2, a prostanoid that, in turn, activates prostaglandin E2 receptors on the central nervous system neurons involved in the general symptoms following burn injury.