Neurological prognosis of 6 cases after chest compression during general anesthesia.

INTRODUCTION: Data on the outcomes after chest compression (CC) of patients who are under general anesthesia (GA) are limited. The present study aimed to evaluate the neurological outcomes in patients who received CC while under GA. METHODS: The patients who received CC while under GA, between 2010 and 2015, in Kyoto Medical Center were surveyed retrospectively. The primary outcome was poor neurologic function or death, as defined by a cerebral performance category score (CPC) score of 3-5 on day 28. RESULTS: Six patients received CC while under GA, and four patients had poor neurological outcomes with a CPC score of 4 or 5 on day 28. All these patients required emergency operation because of their primary disease. CONCLUSION: Even if the patients were monitored and immediately managed under GA, ineffective management of preoperative conditions tended to result in the poor neurological prognosis.

Inter-rater reliability of the American Society of Anesthesiologists physical status rating for emergency gastrointestinal surgery.

Aim: The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is used worldwide and has also been incorporated into various prediction rules. However, concerns have been raised regarding inter-rater agreement in various surgical fields. Although emergency gastrointestinal surgery is relatively common and associated with high postoperative mortality, a reliability study has not yet been undertaken in this field. The aim of the present study was to investigate the inter-rater reliability of ASA-PS for emergency gastrointestinal surgery. Methods: Three sets of scenarios were generated for each ASA-PS class (2E, 3E, and 4E) in emergency gastrointestinal surgery, resulting in nine scenarios. These scenarios described the preoperative profiles of patients in one hospital. Two or three anesthesiologists from 18 other hospitals provided scores for ASA-PS for each scenario. Results: Fifty anesthesiologists scored the ASA-PS class. Between 66% and 90% of these anesthesiologists assigned the same ratings as the reference ratings for the individual scenarios. Inter-rater reliability was assessed using Fleiss' kappa (95% confidence interval) of 0.55 (0.54-0.56, P < 0.001) and an intraclass correlation coefficient (95% confidence interval) of 0.79 (0.63-0.93, P < 0.001). Conclusion: The results of the present study revealed the consistency of ASA-PS ratings between anesthesiologists for emergency gastrointestinal surgery. The ASA-PS may serve as a reliable variable in the prediction rules for this field.

[Misplacement of a guidewire into the right vertebral vein through the right internal jugular vein under real-time ultrasound guidance in Trousseau syndrome patient--a case report].

Trousseau syndrome is a venous thromboembolic complication found in abdominal cancer patients. A 46-year-old woman diagnosed with and treated for pulmonary embolism due to Trousseau syndrome with a huge ovalian tumor was planned to undergo oophorectomy. She presented with pulmonary hypertension and her inferior vena cava was compressed by the tumor. After induction of general anesthesia, ultrasound-guided central venous catheterization (CVC) to her right internal jugular vein was tried. The guidewire was misplaced in the vertebral vein through the right internal jugular vein. Her vertebral vein was abnormally dilated. The dilated vertebral vein was supposed to have worked as a venous perfusion route from the lower extremities. When the CVC was performed in patients with restricted venous return due to Trousseau syndrome, deep-seated veins as well as arteries should be checked with ultrasonography.

Postoperative continuous intravenous infusion of fentanyl is associated with the development of orthostatic intolerance and delayed ambulation in patients after gynecologic laparoscopic surgery.

PURPOSE: Early ambulation is essential for rapid functional recovery after surgery; however, orthostatic intolerance may delay recovery and cause syncope, leading to potential serious complications such as falls. Opioids may contribute to orthostatic intolerance because of reduced arterial pressure and associated reduction in cerebral blood flow and oxygenation. This study aimed to examine the effect of postoperative continuous infusion of fentanyl on orthostatic intolerance and delayed ambulation in patients after gynecologic laparoscopic surgery. METHODS: In this retrospective cohort study, data from 195 consecutive patients who underwent gynecologic laparoscopic surgery were analyzed to evaluate the association between postoperative continuous infusion of fentanyl and the incidence of orthostatic intolerance or delayed ambulation. The primary outcome was defined as delayed ambulation, an inability to ambulate on postoperative day 1. The secondary outcome was defined as orthostatic intolerance and symptoms associated with ambulatory challenge, including dizziness, nausea and vomiting, feeling hot, blurred vision, and eventual syncope. Multivariate logistic regression was used to determine the independent predictors of delayed ambulation and orthostatic intolerance. RESULTS: There were 24 cases with documented orthostatic intolerance and 5 with delayed ambulation. After multivariate logistic regression modeling, postoperative continuous infusion of fentanyl was found to be significantly associated with both orthostatic intolerance [adjusted odds ratio (95% confidence interval), 34.78 (11.12-131.72)] and delayed ambulation [adjusted odds ratio (95% confidence interval), 8.37 (1.23-72.15)]. CONCLUSION: Postoperative continuous infusion of fentanyl is associated with increased orthostatic intolerance and delayed ambulation in patients after gynecologic laparoscopic surgery.

Dopamine D2-like receptor in the nucleus accumbens is involved in the antinociceptive effect of nitrous oxide.

BACKGROUND: The mechanism of the antinociceptive effects of nitrous oxide (N(2)O) has not been completely elucidated. On the other hand, numerous studies have indicated that mesolimbic dopaminergic neurons, which are thought to be involved in rewarding and reinforcement processes, play important roles in the supraspinal pain-suppression system. We hypothesized that the mesolimbic dopaminergic system is involved in the antinociceptive effect of N(2)O. METHODS: Adult male Fischer rats were used in this study. To examine whether the dopaminergic system is activated by N(2)O, frozen sections of the ventral tegmental area of rats exposed to 75% N(2)O were double-stained for c-Fos and tyrosine hydroxylase. To clarify whether the dopaminergic system is involved in the antinociceptive action of N(2)O, saline or raclopride, a dopamine D(2)-like receptor antagonist, was injected into the nucleus accumbens (NAc) shell region. After exposure to 25% oxygen-75% nitrogen or 25% oxygen-75% N(2)O for 30 min, rats were subjected to formalin test, and the spinal cord was examined immunohistochemically. RESULTS: Exposure to 75% N(2)O increased c-Fos expression in tyrosine hydroxylase-positive cells in the ventral tegmental area. Raclopride, injected into the NAc shell region, attenuated the antinociceptive effect of N(2)O in the formalin test, and blocked the suppressive effect of N(2)O on the formalin-induced c-Fos expression in the dorsal horn of the spinal cord by N(2)O. CONCLUSION: It is possible that inhalation of N(2)O activates mesolimbic dopaminergic neurons, and that the antinociceptive effect of N(2)O is at least partially mediated by dopamine D(2)-like receptors in the NAc shell region.

Nitrous oxide increases serotonin release in the rat spinal cord.

The mechanism of the antinociceptive action of nitrous oxide (N(2)O) is not fully understood. It was reported that N(2)O induces opioid peptide release in the rat midbrain, which can activate the descending inhibitory system in the spinal cord. Although effects of N(2)O on the noradrenergic descending inhibitory system have been established, effects of N(2)O on the serotonergic descending inhibitory system have not been extensively investigated. We measured the extracellular level of serotonin by using in vivo microdialysis in the dorsal horn of the spinal cord in rats. The serotonin release increased to 213.01 +/- 24.87% (mean +/- SEM) of the baseline level from 20 to 40 min after applying N(2)O, which was followed by a gradual decrease. It is suggested that the serotonergic descending pathway is activated by N(2)O.

Activity of the serotonergic system during isoflurane anesthesia.

BACKGROUND: Microdialysis studies have demonstrated that the release of serotonin (5-hydroxytryptamine, 5-HT) in the serotonergic projection areas increases during waking and decreases during sleep in rat and cat, suggesting that 5-HT plays an important role in modulation of sleep. Although it might be expected that 5-HT release is also decreased during general anesthesia, the functional contribution of serotonergic neurons in pharmacological effects of volatile anesthetics has not been fully investigated. METHODS: Using an in vivo microdialysis technique, we measured extracellular 5-HT in rat frontal cortex during waking, slow-wave sleep, and isoflurane anesthesia. To assess the involvement of the serotonergic system in the hypnotic action of isoflurane, the concentration of isoflurane required for loss of righting reflex was determined with or without pretreatment of fluoxetine hydrochloride, a selective 5-HT reuptake inhibitor. RESULTS: During slow-wave sleep and isoflurane anesthesia (0.1-1.5 MAC), 5-HT release decreased to 21%-44% of that during the waking state. Loss of righting reflex occurred at significantly higher isoflurane concentrations in fluoxetine-treated rats (0.76% +/- 0.03% [n = 8]) than in control rats (0.60% +/- 0.01% [n = 8]). CONCLUSIONS: It is suggested that a change in the activity of the serotonergic system in the brain is involved in the hypnotic action of isoflurane.

Omission of fentanyl during sevoflurane anesthesia decreases the incidences of postoperative nausea and vomiting and accelerates postanesthesia recovery in major breast cancer surgery.

PURPOSE: Our purpose was to investigate the effect of omission of fentanyl during sevoflurane anesthesia on the incidences of postoperative nausea and vomiting and on postanesthesia recovery in female patients undergoing major breast cancer surgery. METHODS: Female patients (American Society of Anesthesiologists [ASA] physical status [PS] class I-II; age, 28-84 years) undergoing major breast cancer surgery were randomized to one of two anesthesia maintenance groups: sevoflurane-fentanyl anesthesia (SF; n = 25) or fentanyl-free sevoflurane anesthesia (S; n = 26). All patients were administered with propofol 2 mg x kg(-1) intravenously for anesthesia induction, a laryngeal mask airway was placed, and they received rectal diclofenac and local infiltration anesthesia. Anesthesia was maintained with sevoflurane in oxygen-air and they breathed spontaneously. The patients in group SF received fentanyl 0.1 mg intravenously and those in group S received normal saline during anesthesia. RESULTS: Group SF revealed higher incidences of postoperative nausea (68% vs 27%) and vomiting (32% vs 8%) in the first 24 postoperative hours than group S. The median (25th-75th percentile) length of time from postanesthesia care unit (PACU) admission to ambulation was significantly longer in group SF (n = 23) at 195 min (158-219 min), than in group S, at 141 min (101-175 min). Two patients in group SF could not walk during the PACU stay. CONCLUSION: Omission of fentanyl during sevoflurane anesthesia, combined with diclofenac and local infiltration anesthesia, decreases the incidences of postoperative nausea and vomiting and accelerates postanesthesia recovery in patients undergoing major breast cancer surgery.

The involvement of the nociceptin receptor in the antinociceptive action of nitrous oxide.

Nociceptin and its receptor are widely expressed in the central nervous system and are involved in the modulation of nociception. We have previously reported that the minimum anesthetic alveolar concentrations for volatile anesthetics do not differ between nociceptin receptor knockout (NOP-/-) mice and wild-type (NOP+/+) mice. In the present study, we investigated whether the nociceptin system is involved in the antinociceptive action of nitrous oxide. Using the acetic acid-induced writhing test, we showed that nitrous oxide had significantly less analgesic action in NOP-/- mice than in NOP+/+ mice. Furthermore, when anesthetized with a mixture of halothane and nitrous oxide (70%), intraperitoneal injection of acetic acid resulted in an increase of plasma adrenocorticotropic hormone concentrations in NOP-/- mice but not in NOP+/+ mice. An immunohistochemical study showed that nitrous oxide exposure induced c-Fos expression in the spinal cords of NOP+/+ mice but not in those of NOP-/- mice. These results together suggest that the antinociceptive action of nitrous oxide is, at least partly, mediated by the nociceptin system.

[Severe pulmonary hypertension during double lung transplantation].

We report a case of severe intraoperative pulmonary hypertension during double lung transplantation. A 31-year-old woman with severe primary pulmonary hypertension underwent double lung transplantation. Although a marked increase in pulmonary arterial pressure (180/80 mmHg) exceeding the level of systemic arterial pressure occurred after anesthetic induction, the operation could be performed with scheduled cardiopulmonary bypass without using urgent percutaneous cardiopulmonary support.

[Anesthetic management of a boy with 7 q trisomy syndrome].

A 5-year-old boy with 7 q trisomy received general anesthesia for tracheostomy. He was born with multiple morphological malformations including anomalies of ears, eyes, face and vertebral, accompanying difficulty in tracheal intubation. At first we inserted a laryngoscope under awake condition to estimate the difficulty in intubation. Then, we performed intubation under sevoflurane-N2O-O2 anesthesia. After intubation, there was no problem during the operation. A child with chromosome abnormality has multiple malformations and we should be ready for possible difficulties.