Fatal case of ST8/SCCmecIVl community-associated methicillin-resistant Staphylococcus aureus infection in Japan.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) with ST8/SCCmecIV threatens human health. However, its pathogenesis remains unclear. ST8 CA-MRSA (CA-MRSA/J) with SCCmecIVl, which carries the large LPXTG-motif-containing putative adhesin gene, spj, has emerged in Japan. We present the first reported case of death from CA-MRSA/J. The patient was a 64-year-old woman with iliopsoas abscesses complicated by septic pulmonary embolism and multiorgan abscesses. Vancomycin, arbekacin, daptomycin and rifampicin were ineffective. CA-MRSA/J was resistant to erythromycin, clindamycin and antiseptics and was invasive in a HEp-2 cell assay, in contrast to skin-derived villous-adherent CA-MRSA/J. This suggests the strongly invasive pathotype of CA-MRSA/J.

[Bronchospasm during crush induction with propofol under the Sellick maneuver in a patient for emergency laparotomy].

A 61-year-old man was scheduled for an emergency laparotomy due to ileus. He had a history of asthma, but it was well controlled without medication. Anesthesia was induced with propofol and ketamine under the Sellick maneuver. Following administration of vecuronium, endotracheal intubation was performed. However, he could not be ventilated. We thought that the tube had been inserted into the esophagus, and re-intubation was performed. However he could not be ventilated as in the first trial. At that time, we suspected that bronchospasm had occurred. Bronchospasm improved rapidly using hyperventilation with 100% oxygen and 3-5% sevoflurane, and intravenous aminophylline. Because he had a history of asthma, propofol was relatively indicated from the point of smooth muscle relaxant effects. However we should consider the risk of bronchospasm in a patient with a history of asthma, even if we use propofol.

[Safety of continuous epidural anesthesia during heart surgery--change of coagulation-fibrinolysis under heparinization].

To confirm the safety of continuous epidural anesthesia during extracorporeal circulation under heparinization, we investigated epidural hematoma formation following the cardiopulmonary bypass in both humans and dogs. In fifteen dogs, divided into three groups, heparin was administered at the dose of 300, 600, or 900 U.kg-1, respectively. In fourteen patients, a dose of 300 U.kg-1 haparin was administered for cardiopulmonary bypass. Although blood coagulation-fibrinolysis dropped into abnormal ranges following heparinization, no epidural hematoma was observed in dog and no patient revealed spinal complication associated with epidural hematoma. These data indicate that continuous epidural anesthesia would be a safe tool for intraoperative anesthesia even during extracorporeal circulation under heparinization.

Cutaneous responsiveness of lumbar spinal dorsal horn neurons is reduced by general anesthesia, an effect dependent in part on GABAA mechanisms.

Extracellular activity was recorded from single spinal dorsal horn neurons in both chronic cat and acute rat models. This was done to define the effects of anesthesia on the processing of sensory information elicited by nonnoxious tactile stimulation of peripheral receptive fields (RFs). In the chronic cat model, baseline data were obtained in physiologically intact, awake, drug-free animals before anesthetic administration (halothane 1.0-2.0%). This made it possible to compare and contrast activity of each cell in the drug-free and anesthetized state. Halothane effects were confirmed in the acute rat model (anesthetized, spinally transected, and in some cases decerebrate). In addition, the gamma-aminobutyic acid-A (GABAA)-receptor antagonist picrotoxin (2 mg/kg) was administered intravenously to verify that the observed halothane effect on spinal dorsal horn neurons was mediated by an interaction with GABAA-receptor systems. Halothane effects on three separate measures of response to nonnoxious tactile stimuli were observed in the chronic cat model. Halothane produced a significant, dose-dependent reduction in the low-threshold RF area of the neurons studied. Halothane also caused a significant reduction in neuronal response to RF brushing (dynamic stimulus) and to maintained contact with the RF (static stimulus). A dose dependency was not observed with these latter two effects. Neurons with a predominant rapidly adapting response seemed to be less susceptible to halothane suppression than slowly adapting cells. In the acute rat model an increase in halothane caused a reduction in neuronal response similar to that seen in the cat. The intravenous administration of 2 mg/kg of picrotoxin by itself caused no significant change in RF size or response to brushing. However, the same amount of picrotoxin did cause a 50% reversal of the halothane-induced reduction in RF size without causing a significant change in the halothane effect on response to RF brushing. In contrast to work recently reported in a chronic sheep model, halothane causes a significant reduction in spinal dorsal horn neuronal response to tactile stimulation of peripheral RFs. This effect is caused by, in part, but not exclusively, to GABAA-neurotransmitter systems. However, the relative influence of GABAA systems may vary with the nature of the stimulus.

Spinal anesthesia with tetracaine in 0.75% glucose: influence of the vertebral interspace used for injection.

BACKGROUND AND OBJECTIVES: The anesthetic behavior and hemodynamic consequences of spinal anesthesia with marginally hyperbaric tetracaine containing a low concentration of glucose injected at two different interspaces were examined and compared with those of conventionally hyperbaric solution. METHODS: One-hundred twenty ASA Physical Status I or II patients scheduled for elective surgery to the lower limb were sequentially assigned to one of three equal groups to receive spinal anesthesia: Group 1 received 0.5% tetracaine in 0.75% glucose with 0.125% phenylephrine at the L2-L3 interspace; group 2 0.5% tetracaine in 0.75% glucose with 0.125% phenylephrine at the L3-L4 interspace; group 3 0.5% tetracaine in 7.5% glucose with 0.125% phenylephrine at the L3-L4 interspace. Neural block was assessed in a double-blinded manner by cold, pinprick, and touch sensation, and a modified Bromage scale after the injection of the study drug. RESULTS: Injection at the L2-L3 interspace produced significantly higher spread of analgesia [median T7 (10th, 90th percentiles T10, T4)] than injection at L3-L4 interspace [T10 (L1, T5)] when using the solution in 0.75% glucose. There were no significant differences in peak dermatomal levels between groups 1 and 3, but the number of patients who required ephedrine for the treatment of hypotension was larger in group 3. CONCLUSIONS: A marginally hyperbaric tetracaine solution injected at the L2-L3 interspace with the patient in the lateral position produced greater extent of cephalad spread than that at the L3-L4 interspace. When compared to a conventionally hyperbaric tetracaine solution injected at the L3-L4 interspace, the marginally hyperbaric solution injected at the L2-L3 interspace caused less hemodynamic variability despite similar levels of maximum sensory block.

[Postoperative brain infarction in a patient with the previous asymptomatic brain infarction].

We report a case of a postoperative brain infarction, in which an asymptomatic preoperative brain infarction was also revealed postoperatively. A 63-year-old man with bladder carcinoma was scheduled for the cystoplasty. The patient had no prominent preoperative abnormality. Anesthesia was maintained with isoflurane in N2O/oxygen combined with a spinal block and a continuous epidural block. Anesthesia lasted uneventfully for 16.5 hours. However, emergence from anesthesia was delayed. On the first postoperative day, motor aphasia and right hemiparalysis was confirmed. The computed tomography (CT) of the brain demonstrated a low density area in the frontoparietal region. The magnetic resonance imaging (MRI) indicated the corresponding lesion as the CT had demonstrated, and an old brain infarction in the parietal region. This meant that the patient had a history of asymptomatic brain infarction (ABI). Patients with ABI are considered to be a high-risk group for a brain infarction. It is important to evaluate the risk factors of brain infarction preoperatively and to minimize those risks during the operation. Maintenance of the cerebral perfusion pressure is imperative.

Antinociceptive effects of ONO-9902, an enkephalinase inhibitor, after visceral stress condition in rats.

PURPOSE: The present study was designed to examine the antinociceptive effects of orally administered ONO-9902, an enkephalinase inhibitor, on both somatic and visceral pain after visceral stress conditions. METHODS: Twenty six male rats were examined. Tail-flick (TF) and colorectal distension (CD) tests were used to determine somatic and visceral antinociceptive effects, respectively. Measurements were performed in rats under immediate post-stress conditions (group ST; n = 14) and in rats nor under stress conditions (group NST; n = 12). In the stressed group, the same device, CD, for visceral antinociceptive effects was used for visceral stress and was applied with an intracolonic pressure of 60 mmHg for 20 min after drug administration. The TF latency and CD threshold were measured before and at 30, 40, 50, 60 and 90 min after administration of ONO-9902 300 mg.kg-1 or distilled water. RESULTS: Orally administered ONO-9902 did not produce any changes in the % maximum possible effect (%MPE) in either TF or CD tests in the unstressed group. In the stressed group, %MPE in the CD test increased 18% and 31% at 30 and 40 min, respectively, after oral administration of ONO-9902 compared with the control group (P < 0.05). However, %MPE to TF test did not alter even after the CD-induced stress condition. CONCLUSION: These results suggest that ONO-9902 may have analgesic effects on visceral pain but not on somatic pain under immediate post-stress conditions.

Halothane effects on low-threshold receptive field size of rat spinal dorsal horn neurons appear to be independent of supraspinal modulatory systems.

Recent evidence strongly supports the importance of spinal sites of action for the ability of general anesthetic agents to block response to noxious stimuli. This study was designed to examine possible spinal anesthetic effects on non-noxiously evoked activity. Three groups of rats were prepared for acute experiments in which the response of spinal dorsal horn neurons to low threshold receptive field (RF) stimulation was evaluated. In each animal in each group extracellular activity was recorded from a single spinal dorsal horn neuron. A low-threshold RF of each neuron and, at times, the sensitivity to low-threshold stimulation of multiple sites in the RF were determined under baseline conditions (light anesthesia or decerebrate). In Group 1, reversible cooling of the thoracic spinal cord in the presence of either 0.5% or 1% halothane anesthesia caused no change in RF size. However, an increase from 0.5% to 1% halothane caused a 53% decrease in RF size both in the presence and absence of a reversible cold block of the spinal cord. In Group 2, animals with spinal cords transected at the thoracic level had a similar change in low-threshold receptive field size (52%) when halothane concentrations were increased from 0.5% to 1%. Testing sensitivity within the RF areas indicated that the silenced areas at the fringe of the receptive field could still elicit activation of spinal dorsal horn neurons but at a higher threshold. In the final group of animals, decerebration and spinal cord transection allowed us to compare effects of 0.5% and 1% halothane with an anesthetic free baseline. Here, again, a dose-dependent reduction in RF area was observed although the baseline RFs were significantly smaller than those in Groups 1 and 2. These results demonstrate that the reduction in low-threshold receptive field size due to the administration of the inhalation anesthetic halothane occurs in the absence of descending modulation from supraspinal sites. This implicates the spinal dorsal horn as a potentially important site of action for general anesthetics. These results also support the spinal cord as an important tool to study the pharmacology responsible for anesthetic effects on sensory processing.

Low-threshold neuronal activity of spinal dorsal horn neurons increases during REM sleep in cats: comparison with effects of anesthesia.

1. Cats were prepared for chronic recordings from the lumbar enlargement of the spinal dorsal horn. At the beginning of each recording session, a tungsten microelectrode was advanced through the dura in a physiologically intact, awake, drug-free animal, until amplitude discrimination provided a single neuron with a receptive field on the hindquarters. 2. Extracellular recordings of activity of each neuron were made during receptive field stimulation with tactile and thermal nonnoxious and noxious stimuli. 3. Baseline responses obtained in the awake state were compared with responses of the same neurons during slow-wave or rapid-eye-movement (REM) sleep. In a subpopulation of neurons, the effects of anesthesia (propofol, 7.5 mg/kg iv) were observed after the completion of sleep studies. 4. The low-threshold receptive fields of the seven neurons studied during REM sleep were all increased in size when compared with the baseline value. The average increase was 52.6% (range 26.2-96.7%). 5. The low-threshold receptive fields of the seven neurons studied during REM sleep were reduced by propofol anesthesia by an average of 49.1% (range 29-74%). 6. Neuronal response to receptive field brushing was observed in 15 neurons during REM sleep. The effect of propofol on receptive field brushing was observed in 8 of those neurons. In only one of those eight neurons were the effects of REM sleep and anesthesia in the same direction. 7. Changes in neuronal responses were less consistent during slow-wave sleep but still differed from changes induced by propofol.(ABSTRACT TRUNCATED AT 250 WORDS)

Utilization of a glucose/fructose/xylitol carbohydrate solution during surgery.

The utilization of a 4:2:1 mixture of glucose, fructose, and xylitol (GFX) was studied by indirect calorimetry in patients undergoing abdominal surgery. Sixteen patients undergoing gastrectomy under general anesthesia received GFX intravenously at 0.25 g/kg h-1 during surgery. VO2, VCO2, and RQ were measured continuously for 150 min using an Engström metabolic computer, and urea nitrogen excretion was determined at 30-min intervals during surgery. Blood levels of glucose, fructose, and xylitol plateaued after 1 h. The RQ decreased over the first 90 min from 0.84 +/- 0.06 to 0.75 +/- 0.05 and then gradually increased to 0.79 +/- 0.04 at 150 min. VO2 did not change significantly over the 150-min period. From the RQ, VO2, and nitrogen excretion data, carbohydrate oxidation was estimated. The amount of carbohydrate oxidized was 9.7 +/- 6.9 g during the first 30-min period, 3.5 +/- 5.2 g during the 60 to 90-min period, and 7.5 +/- 4.5 g in the 120 to 150-min study period. Simultaneously, lipid oxidation increased. These observations suggest that the GFX solution is adequately metabolized during surgery and therefore may be a suitable energy source for patients.

Histological detection of lipid peroxidation following infusion of tert-butyl hydroperoxide and ADP-iron complex in perfused rat livers.

Lipid peroxidation was assessed histologically and biochemically in hemoglobin-free perfused rat livers using two different types of stimulators. The Schiff reaction of fuchsin with cellular aldehydes was used as a histological index for lipid peroxidation. t-Butyl hydroperoxide (BHP, 0.8 mM) infusion caused a rapid and sustained release of thiobarbituric acid reactive substances (TBARS) into the effluent perfusate for up to 60 min, which was accompanied by lactate dehydrogenase (LDH) leakage after 30 min. The Schiff positive foci were initially restricted to periportal zones and spread with time to whole areas, accompanied by periportal necrosis. Coinfusion of diphenyl-p-phenylenediamine suppressed the TBARS release, with negative fuchsin staining, but the LDH leakage was unaffected. Under retrograde perfusion, BHP produced pericentral staining and necrosis. With 2.5 mM ADP-100 microM Fe3+, little TBARS was released up to 60 min, even though the hepatic TBARS levels increased considerably by this time. By 90 min, marked TBARS release occurred, but LDH leakage remained low. Irrespective of the direction of perfusion, pericentral hepatocytes became Schiff positive after 30 min. The fuchsin staining method may be useful for detecting peroxidized zones of the liver lobules.

Histological evidence for dissociation of lipid peroxidation and cell necrosis in bromotrichloromethane hepatotoxicity in the perfused rat liver.

Bromotrichloromethane (CBrCl3)-induced hepatic lipid peroxidation and cell necrosis were studied histologically and biochemically, using isolated perfused livers from phenobarbital-pretreated rats. Lipid peroxidation was assessed by fuchsin staining of the liver slices and release of thiobarbituric acid reactive substances (TBARS) into the perfusate; necrosis was assessed by trypan blue uptake and lactate dehydrogenase (LDH) leakage. A good correlation was observed between the Schiff-positive reaction and TBARS release under various experimental conditions, supporting the validity of the fuchsin staining method for histological detection of lipid peroxidation. Lobular localization of lipid peroxidation and necrosis was as follows: Under high oxygen supply (95% O2-saturated buffer), infusion of CBrCl3 caused the Schiff-positive reaction in the pericentral to midzonal hepatocytes, irrespective of the direction of perfusion, but did not produce necrosis. Under low oxygen supply (20% O2) with retrograde perfusion, dissociation of lipid peroxidation and necrosis was observed, i.e., trypan blue uptake in the periportal zones and Schiff-positive staining in the pericentral hepatocytes. Thus, lipid peroxidation by itself may have a relatively minor role in the development of CBrCl3-induced acute hepatic cell death.

[Anesthetic management of caesarean section for the delivery of quadruplets].

Multiple gestation pregnancies are accompanied with risks for both mother and fetuses. Morbidity and mortality of both of them are increased compared with singleton pregnancies. We have presented a case of a 30-year-old parturient with quadruplets. The pregnancy had been complicated by premature labour, anemia, toxemia, coagulopathy, pulmonary congestion and malpresentation. On the 29th week of pregnancy, an elective Caesarean section was scheduled. There is no ideal anesthetic technique for quadruplets. In this case general anesthesia was chosen, because she had coagulopathy. The anesthesia and postoperative course were uneventful. The patient and the four babies had no complication nor sequela on their discharge. The anesthetic considerations for multiple gestation pregnancies were also discussed.

[Successful management of abdominal aortic aneurysm due to bacterial infection: report of a case].

A successful surgery of abdominal aortic aneurysm due to bacterial infection is described. The patient, 71-year-old man, had been suffering from high fever of unknown origin which had narrow escape with the several kinds of antibiotics about a month and more. During the antibiotic therapy in another hospital, he was diagnosed as an abdominal aortic aneurysm by whole body computed tomography. Immediately after the arrival to our hospital, digital subtraction angiography was done, and it showed a saccular aneurysm in the infrarenal abdominal aorta. Surgical removal of this aneurysm without opening of the aneurysmal wall was performed and the kitted dacron graft was used for aorto-biiliac anastomosis. The diagnosis of aneurysm due to bacterial infection was confirmed by bacteriological and pathological examinations. The patient in now surviving 17 months after operation. Abdominal aortic aneurysm due to bacterial infection is a serious disorder that generally carries grave prognosis. Complete removal of infected lesion without contamination and long-term follow-up with antibiotic chemotherapy are essential for this disease.