[Case of ulnar nerve palsy in a patient with a history of total elbow arthroplasty after abdominal surgery under general anesthesia].

Ulnar nerve palsy is a well recognized complication of the general anesthesia. We experienced a case of ulnar nerve palsy after abdominal surgery under general anesthesia in a patient with a history of total elbow arthroplasty and ulnar nerve translocation. It appears that pressure on medial epicondyle caused the palsy and that the position of the ulnar nerve has to be carefully examined before surgery in a patient with a history of total elbow arthroplasty and ulnar nerve translocation.

Forces applied to the maxillary incisors during tracheal intubation and dental injury risks of intubation by beginners: a manikin study.

OBJECTIVES: We wished to determine whether dental injuries during intubation would occur more frequently when performed by inexperienced beginners. We measured the laryngoscopic force exerted on maxillary teeth of a modified manikin by experienced anesthesiologists and unexperienced medical students and estimated the injury risk. METHODS: Thirty-two anesthesiologists and 32 medical students participated in this study. Each testee performed tracheal intubation in two scenarios in a random order. In Scenario 1, the testee performed tracheal intubation for a manikin as a patient with normal dentition, in an emergency type situation. In Scenario 2, the testee performed tracheal intubation for a manikin as a patient with unstable dentition, in a routine anesthetic situation. RESULTS: The mean peak forces in Scenarios 1 and 2 were 6.1 and 1.1 N in the experienced testee group and 7.7 and 3.8 N in the unexperienced testee group, respectively (Scenario 2, p < 0.05). The unexperienced group applied higher forces than the experienced group in the nonemergency situation. However, the maximum force applied by the inexperienced group was 40.2 N, which is substantially lower than the maximum bite force of normal incisors (150-200 N). CONCLUSION: Our results suggest that the experience levels of the laryngoscopists are not a major determinant of dental injuries in patients with healthy dentition.

Unilateral adrenalectomy attenuates hemorrhagic shock-induced analgesia in rats.

PURPOSE: To assess the importance of the pituitary adrenal axis in producing stress-induced analgesia (SIA) after hemorrhagic shock, we performed formalin tests after hemorrhage and reinfusion in unilaterally adrenalectomized or sham-operated rats. METHODS: Fifty-two adult Sprague-Dawley rats were divided into seven groups: sham-operation normotensive (n = 8), sham-operation shock (n = 8), adrenalectomy normotensive (n = 7), adrenalectomy shock (n = 7), sham-operation shock + yohimbine (n = 7), sham-operation normotensive + corticosterone (n = 7), and adrenalectomy shock + corticosterone (n = 8). The left adrenal gland was cauterized 24 h before the experiment. The mean blood pressure in the shock groups was kept at 50-60 mmHg for 30 min by draining arterial blood. After the blood-reinfusion or observation period, 10% formalin was injected into the rear paw. Nociceptive behaviors and locomotion were observed and rated for 1 h, using the criteria of Dubuisson and Dennis. In 12 other sham-operated and adrenalectomized rats, plasma adrenalin, noradrenalin, and corticosterone concentrations were measured before and after hemorrhagic shock. RESULTS: Although the sham-operation shock group showed a lower pain score, the adrenalectomy shock group showed nociceptive behavior similar to that in the normotensive groups. Yohimbine did not affect the SIA; however, corticosterone administration reversed the effects of the adrenalectomy on the SIA. The plasma corticosterone levels in the unilaterally adrenalectomized rats were lower than those in the sham-operated rats and did not increase after hemorrhagic shock. CONCLUSION: These results suggest that adrenocortical systems play an important role in hemorrhagic shock-induced SIA.

Site of fresh gas inlet and ratios of the delivered fraction and inspired fraction of inhaled isoflurane and sevoflurane in low-flow anesthesia.

PURPOSE: The use of low-flow anesthesia causes a discrepancy between the delivered fraction (FD) and the inspired fraction (FI) of inhaled gases. We compared the FI/FD ratios of a new circle (fresh gas inlet located between the inspiratory valve and the patient) to those of the conventional circle (fresh gas inlet located between the inspiratory valve and the CO2 absorber) in low-flow isoflurane and sevoflurane anesthesia, using three anesthetic machines (Dräger NM-GS, Dräger Fabius-GS, and ACOMA KMA-1300-III). METHODS: Eighty-two patients were randomly assigned to three experimental groups. For experiment 1, 32 patients were allocated to the NM-GS conventional/new, NM-GS new/conventional, ACOMA conventional/new, and ACOMA new/conventional groups. For experiment 2, 14 patients were allocated to ACOMA conventional/conventional and ACOMA new/new groups to measure isoflurane FI/FD ratios. For experiment 3, 36 patients were allocated to ACOMA conventional/conventional, ACOMA new/new, Fabius conventional/conventional, and Fabius new/new to measure sevoflurane FI/FD ratios. RESULTS: In experiment 1, the NM-GS showed no significant changes in the FI/FD ratios. However, in the ACOMA, the new circle improved the FI/FD ratio. In experiment 2, the isoflurane FI/FD ratios in the new circle of the ACOMA were significantly higher than those in the conventional circle. In experiment 3, the sevoflurane FI/FD ratios in the new circle of both the ACOMA and the Fabius were significantly higher than those in the conventional circles. CONCLUSION: The positioning of the fresh gas inlet between the inspiratory valve and the patient improved the FI/FD ratios of both isoflurane and sevoflurane during low-flow anesthesia in two decoupling-style anesthetic machines (ACOMA and Fabius).

Systemic clonidine activates neurons of the dorsal horn, but not the locus ceruleus (A6) or the A7 area, after a formalin test: the importance of the dorsal horn in the antinociceptive effects of clonidine.

PURPOSE: In order to clarify the principal site for the antinociceptive effects of clonidine, we investigated the nociceptive behavior and neural activity (c-fos staining) of the dorsal horn (DH), locus ceruleus (LC), and A7 area after a formalin test in normal saline- or clonidine-injected rats. METHODS: Thirty-six rats were divided into 6 groups as follows: formalin test + saline (FS); formalin test + clonidine (1 mg.kg(-1)) (FC1); formalin test + clonidine (10 mg.kg(-1)) (FC10); saline (S); clonidine (1 mg.kg(-1)) (C1); and clonidine (10 mg.kg(-1)) (C10). Normal saline or clonidine was injected intraperitoneally 30 min before the formalin test. In the FS, FC1, and FC10 groups, 10% formalin was injected into the left rear paw. All rats were killed 2.5 h after normal saline or clonidine injection. Sections of the lumbar spinal cord, LC, and A7 area were processed for c-fos immunohistochemistry using the avidin-biotin peroxidase complex method. To evaluate the sedative effects of clonidine, we investigated the loss of righting reflex (LORR) for 90 min in 6 other rats as follows: clonidine (1 mg.kg(-1)) (n = 3) and clonidine (10 mg.kg(-1)) (n = 3). RESULTS: The FC10 group showed fewer nociceptive behaviors and higher c-fos expression in the DH, but not in the A7 area, as well as lower c-fos expression in the LC than rats in the FS and FC1 groups (P < 0.05). The C10 group showed lower c-fos expression in the LC than that of rats in the S and C1 groups (P < 0.05). No rats exhibited LORR. CONCLUSION: The antinociceptive effects of clonidine might be mediated primarily by neural activity in the DH.

Respiratory failure due to morbid obesity in a patient with Prader-Willi syndrome: an experience of long-term mechanical ventilation.

Prader-Willi syndrome (PWS) is characterized by obesity, mild mental retardation or learning disability, and behavior problems, especially in association with food and eating. A 19 year-old man, 150 cm, 140 kg (body mass index [BMI], 62.2 kg.m(-2)), whose condition had been diagnosed as PWS, received 41-day mechanical ventilation because of respiratory failure, chiefly due to morbid obesity. Because the patient frequently developed bronchoconstriction, metered-dose inhalers of a corticosteroid (beclomethasone dipropionate) and a beta2 agonist (salbutamol) were needed. To achieve adequate sedation, which was also crucial to control the bronchoconstriction, the concurrent use of midazolam, fentanyl, ketamine, and propofol was required. Pressure-control ventilation was useful to avoid high airway pressure due to low respiratory system compliance associated with the morbid obesity. Because it appeared that the basic problem leading to respiratory failure in this patient was morbid obesity, body weight reduction was considered to be mandatory. Thus, caloric intake was limited to 1000 kcal.day(-1), resulting in body weight reduction by 50 kg during the patient's stay in the intensive care unit (ICU). The patient was successfully extubated on ICU day 35.

Moderate hypercapnia-induced anesthetic effects and endogenous opioids.

The purpose of this report is to explore the mechanisms of hypercapnia-induced antinociception. We carried out three experiments, the first to confirm whether moderate hypercapnia induces anesthetic effects, the second to determine whether naloxone reverses the anesthetic effects, and the third to evaluate whether beta-endorphin is related to the anesthetic effects. In a pre-test, we determined the optimal CO(2) concentration in a chamber which would cause moderate hypercapnia in rats. Eighteen rats were divided into control, hypercapnia, and hypercapnia plus naloxone groups in experiment 1. The naloxone group rats were injected with naloxone (10 mg/kg) intraperitoneally before gas inhalation. After 60 min gas inhalation, 10% formalin was injected into the left rear paw of all rats, and nociceptive behaviors were observed for 1 h. In experiment 2, 11 rats were divided into control and hypercapnia groups. The brain was removed and fixed under pentobarbital anesthesia. Sections were immunostained for c-Fos and beta-endorphin (ACTH) with the ABC method. All neurons double-labeled for c-Fos and beta-endorphin (ACTH) in the arcuate nucleus were counted by blinded investigators. Moderate hypercapnia (PaCO(2) 83+/-7 mmHg) reduced nociceptive behavior in the formalin test and naloxone pre-treatment attenuated this phenomenon. However, beta-endorphin-producing neurons were not activated by CO(2) inhalation. Endogenous opioids are related to moderate, hypercapnia-induced anesthetic effects, but, beta-endorphin-producing neurons in the hypothalamus were not activated by the CO(2) inhalation stress.

Licking and c-fos expression in the dorsal horn of the spinal cord after the formalin test.

We investigated whether c-fos expression in the dorsal horn is affected by licking in the formalin test. Thirty adult Sprague-Dawley rats were divided into 5 groups of 6 rats each: a free condition control (Free Cont) group, formalin test under free condition (Free F-test) group, scrub stimulation under free condition (Free Scrub) group, restrained condition control (Restricted Cont) group, and formalin test under restrained condition (Restricted F-test) group. Animals in the three free condition groups and two restricted groups were put in a clear plastic chamber and a restraining chamber, respectively. Ten percent formalin was injected into the left rear paw in the Free and Restricted F-test groups. Animals in the Free Scrub group were scrubbed on the left rear paw with a wet cotton swab. The Free Cont, Restricted Cont, and Free Scrub groups showed little c-fos expression. The number of c-fos positive cells in the ipsilateral surface dorsal horn of the Restricted F-test group was significantly less than that of the Free F-test group (P < 0.05). The results indicated that the licking action increased c-fos expression of the lumbar dorsal horn in the formalin test.

Effect of propofol on ropivacaine metabolism in human liver microsomes.

A combination of the general anesthetic propofol and epidural anesthesia with a local anesthetic is widely used. The metabolism of ropivacaine and that of lidocaine are mediated by similar P450 isoforms. Previously, propofol was found to inhibit the metabolism of lidocaine in vitro. Here we investigated whether propofol inhibits the metabolism of ropivacaine using human liver microsomes in vitro. Ropivacaine (6.0 micromol.l(-1)) as the substrate and propofol (1-100 micromol.l(-1)) were reacted together using human microsomes. The concentrations of ropivacaine and its major metabolite 2',6'-pipecoloxylidide (PPX) were measured using high-performance liquid chromatography. The metabolic activity of ropivacaine was reflected in the production of PPX. The inhibitory effects of propofol on ropivacaine metabolism were observed to be dose-dependent. The IC50 of propofol was 34.9 micromol.l(-1). Propofol shows a competitive inhibitory effect on the metabolism of ropivacaine (i.e., PPX production mediated by CYP3A4) in human CYP systems in vitro.

CYP2C19 genotype affects diazepam pharmacokinetics and emergence from general anesthesia.

OBJECTIVES: Diazepam is widely used to relieve preoperative anxiety in patients. The objective of this study was to investigate the effects of polymorphism in CYP2C19 and the effects of CYP3A4 messenger ribonucleic acid (mRNA) content in blood on recovery from general anesthesia and on diazepam pharmacokinetics. METHODS: Sixty-three Japanese patients were classified into the following 3 genotype (phenotype) groups on the basis of polymerase chain reaction-restriction fragment length polymorphism analysis of CYP2C19 polymorphism: no variants, *1/*1 (extensive metabolizer [EM]); 1 variant, *1/*2 or *1/*3 (intermediate metabolizer [IM]); and 2 variants, *2/*2, *2/*3, or *3/*3 (poor metabolizer [PM]). We assessed the effects of these polymorphisms and of CYP3A4 mRNA content in the lymphocytes on the patients' recovery from general anesthesia. RESULTS: CYP2C19 genotyping analysis in the 63 subjects showed that 32%, 46%, and 22% of subjects were classified into the EM, IM, and PM groups, respectively. The PM subjects showed a larger area under the curve representing the concentration of diazepam over a 24-hour period (AUC(0-24)) (2088 +/- 378 ng/mL.h(-1), P = .0259), lower clearance of diazepam (0.049 +/- 0.009 L.h(-1).kg(-1), P = .0287), and longer emergence time (median, 18 minutes; 25th-75th percentile range, 13-21 minutes; P < .001) in comparison with subjects in the EM group (AUC(0-24), 1412 +/- 312 ng/mL; clearance, 0.074 +/- 0.018 L.h(-1).kg(-1); and emergence time, 10 minutes, 8-12 minutes [median and 25th-75th percentile range]). The IM group also showed a longer emergence time (median, 13 minutes; 25th-75th percentile range, 9-20 minutes; P < .001) and a larger variation in this parameter in comparison with the EM group. The distributions of the CYP2C19 genotype were significantly different between the 2 groups (rapid emergence <20 minutes, slow emergence >20 minutes) (P = .0148). The mean value of the CYP3A4 mRNA level in the slow-emergence group (mean +/- SD, 4.80 +/- 3.99 x10(-10)) was significantly lower than that of the rapid-emergence group (mean +/- SD, 12.50 +/- 11.90 x10(-10)) (P = .0315). However, there was no significant correlation between emergence time and CYP3A4 mRNA levels (r = 0.239, P = .0601). CONCLUSION: We found that the CYP2C19 genotype affects diazepam pharmacokinetics and emergence from general anesthesia and that the slow-emergence group possesses lower levels of CYP3A4 mRNA than are found in the rapid-emergence group.

Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation.

BACKGROUND: Expiratory rib-cage compression, a chest physiotherapy technique, is well known as the "squeezing" technique in Japan. OBJECTIVE: To determine the effects of rib-cage compression on airway-secretion removal, oxygenation, and ventilation in patients receiving mechanical ventilation. SETTING: An intensive care unit of an emergency and critical care center at a tertiary-care teaching hospital in Tokyo, Japan. METHODS: Thirty-one intubated, mechanically ventilated patients in an intensive care unit were studied in a randomized, crossover trial. The patients received endotracheal suctioning with or without rib-cage compression, with a minimum 3-hour interval between the 2 interventions. Rib-cage compression was performed for 5 min before endotracheal suctioning. Arterial blood gas and respiratory mechanics were measured 5 min before endotracheal suctioning (baseline) and 25 min after suctioning. The 2 measurement periods were carried out on the same day. RESULTS: There were no significant differences in the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, P(aCO2), or dynamic compliance of the respiratory system between the 2 periods (before and after endotracheal suctioning). Moreover, there were no significant differences in airway-secretion removal between the 2 periods. CONCLUSIONS: This study suggests that rib-cage compression prior to endotracheal suctioning does not improve airway-secretion removal, oxygenation, or ventilation after endotracheal suctioning in this unselected population of mechanically ventilated patients.

Effects of naloxone on stress-induced analgesia after hemorrhagic shock.

BACKGROUND AND OBJECTIVES: To investigate whether endogenous opioids might be involved in the mechanisms that underlie hemorrhagic shock-induced analgesia, formalin tests were performed after hemorrhage and reinfusion in naloxone pretreated and untreated rats. METHODS: Twenty-four adult male Sprague-Dawley rats were divided into control (n = 6), saline (n = 6), naloxone 10 mg/kg (n = 6), and naloxone 100 mg/kg (n = 6) groups. The mean blood pressure (mBP) was kept at 50 to 60 mm Hg for 30 minutes by draining arterial blood in the saline group and the naloxone groups. After 15 minutes of returning mBP to normal levels by reinfusion of the drained shed blood, 10% formalin (3.7% formaldehyde solution, 0.1 mL) was injected into the left rear paw. Nociceptive behaviors were observed for 1 hour after the formalin injection. RESULTS: Nociceptive behaviors of the posthemorrhagic shock groups were significantly lower than those of the control group. No significant difference was seen in nociceptive behaviors among the saline and naloxone groups. CONCLUSION: Naloxone did not reverse the hemorrhagic shock-induced analgesia, which suggests that endogenous opioids might not be a major factor that governs stress-induced analgesia (SIA) after hemorrhagic shock.

[Case of premature ventricular contraction immediately after electroconvulsive therapy in a depressive patient].

A 42-year-old woman with eating disorder underwent electroconvulsive therapy (ECT) under general anesthesia with thiamylal 150 mg and suxamethonium 60 mg. On her fourth ECT procedure, premature ventricular contraction (PVC) occurred immediately after the treatment. We speculate that increased release of catecholamine by ECT and hypokalemia caused PVC. It seems that she repeated self-vomiting, because she had hypokalemia, metabolic alkalosis, and weight loss of 3 kg in two weeks before arrhythmia episode. We conclude that in the anesthetic management of patients undergoing ECT a careful attention should be given to body weight change and serum electrolyte care before ECT because it is easy to develop electrolyte abnormality by eating disorder of self-emetic type.

[Anesthetic management of a patient with acute idiopathic pandysautonomia].

Acute idiopathic pandysautonomia (AIPD) is a very rare disease with acute onset of impairment in the peripheral sympathetic and parasympathetic nerves. We report the anesthetic management of a patient with AIPD undergoing bladder lithotomy and scrotum abscess drainage. A 64-year-old man had a severe orthostatic hypotension, and was extremely sensitive to intravenous norepinephrine because of denervation hypersensitivity. Before the surgery, the patient was sufficiently hydrated. We planned to administer a vasopressor (phenylephrine) and a vasodilator (nicardipine) at 1/10 of usual doses. After placement of a radial artery catheter, combined epidural and spinal anesthesia was performed with the patient in a right lateral position. Blood pressure decreased slightly after placing him in a supine position. However, no medication was needed, and the patient showed no perioperative complications.

Premedication medicines do not cause drug metabolic interaction with propofol using human liver microsomes in vitro.

OBJECTIVE: Propofol (2,6-diisopropylphenol) is widely used for anesthetic induction as well as for chronic sedation in intensive care units. In this study, we investigated the interaction between propofol and premedications, i.e., psychotropic and antianxiety agents (diazepam, midazolam), hypnotics (thiamylal), local anesthetics (lidocaine), depolarizing muscular relaxants (vecuronium), an antihypertensive (clonidine) and an H2-receptor antagonist (cimetidine) using human liver microsomes in vitro. METHODS: The interaction effects between propofol and premedications were examined using human liver microsomal preparation in vitro. The concentration of propofol was determined by HPLC with UV detection. RESULTS: The apparent Michaelis-Menten constant (Km) and the maximal velocity of total metabolic formation (Vmax) of propofol in human liver microsomes were 123 microM and 26.1 micromol/min per milligram of mg protein, respectively. Seven premedications (diazepam, midazolam, thiamylal, lidocaine, cimetidine, vecuronium, and clonidine) did not inhibit propofol metabolism in human liver microsomes at concentrations within the therapeutic range. CONCLUSIONS: These results showed no interactions between propofol and seven premedication drugs within the therapeutic range of propofol using human liver microsomes in vitro.