Alleviated cerebral infarction in male mice lacking all nitric oxide synthase isoforms after middle cerebral artery occlusion.

PURPOSE: The role of the nitric oxide synthases (NOSs) system in cerebral infarction has been examined in pharmacological studies with non-selective NOSs inhibitors. However, due to the non-specificity of the non-selective NOSs inhibitors, its role remains to be fully elucidated. We addressed this issue in mice in which neuronal, inducible, and endothelial NOS isoforms were completely disrupted. METHODS AND RESULTS: We newly generated mice lacking all three NOSs by crossbreeding each single NOS-/- mouse. In the male, cerebral infarct size at 24 h after middle cerebral artery occlusion (MCAO) was significantly smaller in the triple n/i/eNOSs-/- genotype as compared with wild-type genotype. Neurological deficit score and mortality rate were also significantly lower in the triple n/i/eNOSs-/- than in the WT genotype. In contrast, in the female, there was no significant difference in the cerebral infarct size in the two genotypes. In the male triple n/i/eNOSs-/- genotype, orchiectomy significantly increased the cerebral infarct size, and in the orchiectomized male triple n/i/eNOSs-/- genotype, treatment with testosterone significantly reduced it. Cyclopaedic and quantitative comparisons of mRNA expression levels in cerebral infarct lesions between the male wild-type and triple n/i/eNOSs-/- genotypes at 1 h after MCAO revealed significant involvements of decreased oxidative stress and mitigated mitochondrial dysfunction in the alleviated cerebral infarction in the male triple n/i/eNOSs-/- genotype. CONCLUSIONS: These results provide the first evidence that the NOSs system exerts a deleterious effect against acute ischemic brain injury in the male.

Molecular and morphological description of a novel microsporidian Inodosporus fujiokai n. sp. infecting both salmonid fish and freshwater prawns.

A new microsporidian disease of cultured rainbow trout Oncorhynchus mykiss has recently been confirmed in Japan, and the causative species was tentatively designated as Microsporidium sp. RBT-2021. Involvement of common prawn Palaemon paucidens in its transmission was suggested based on the previous feeding trials, although the microsporidian infection in P. paucidens was not confirmed. In this study, P. paucidens in Lake Biwa, Japan was investigated for microsporidian infection and 4 types of spores (types 1-4) were newly found. The nucleotide sequence of the small subunit ribosomal RNA gene was identical between type 1 and Microsporidium sp. RBT-2021, indicating they are conspecific. However, intriguingly, the spore morphology and the mode of development in fish and prawn were strikingly different. Morphological observations revealed type 1 in the prawn possesses characteristics of the genus Inodosporus Overstreet and Weidner, 1974, while Microsporidium sp. RBT-2021 in the trout exhibited the characteristics of the genus Kabatana Lom, Dyková and Tonguthai, 2000. In the phylogeny, type 1 was placed within a clade comprising Kabatana spp. and Inodosporus octosporus. Based on the morphological and molecular analyses, we describe Microsporidium sp. RBT-2021 as Inodosporus fujiokai n. sp. Together with the success of the previous prawn-feeding trials, this study strongly suggests I. fujiokai n. sp. has a multi-host life cycle utilizing fish and crustacean hosts and different modes of development in each host. Such polymorphic life cycle has barely been known among fish microsporidians. This study also suggests that the genus Kabatana is a junior synonym of the genus Inodosporus.

Current Genetic Status of Nagaremon-charr, a Threatened Morphotype of Salvelinus leucomaenis in the Ane River, Lake Biwa System, Central Japan, With Comments on Its Conservation.

Stream-dwelling white-spotted charr, Salvelinus leucomaenis, populations tend to have unique color and spot patterns in different regions and may even display stream-specific patterns. An extreme edge of such diversity, found in individuals with atypical body color patterns (so-called nagaremon-type charr, a rare morphotype of Salvelinus leucomaenis [hereafter termed nagaremon-charr]), sympatrically occurring with normal-charr, has been reported from only six small isolated populations in Japan. Based on morphological and ecological perspectives, nagaremon-charr has been considered as an intraspecific color variant of white-spotted charr, although the genetic status of nagaremon-charr has not been determined. In this study, genetic diversity and population structure of the nagaremon-charr in a tributary of the Ane River (Lake Biwa system) were investigated through microsatellite and mtDNA analyses. Nagaremon-charr and sympatric normal-charr in the tributary shared the mtDNA haplotypes and were assigned to the same cluster in the STRUCTURE analysis and discriminant analysis of principal components (DAPC). These results suggested that nagaremon-charr in the Ane River is an intra-populational specific color variant of white-spotted charr. Above a waterfall, nagaremon-charr specimens exhibited extremely reduced genetic diversity, indicating that genetic drift may account for the fixation of the nagaremon-morphotype. Normal-charr below the waterfall clustered separately from hatchery-reared charr, indicative of native status of the former. Thus, both nagaremon-charr and normal-charr in the entire Ane River tributary should be conserved.

Regulation of epidermal growth factor receptor expression and morphology of lung epithelial cells by interleukin-1ß.

Accumulating evidences suggested that the overactivation of epidermal growth factor receptor (EGFR) was involved in the development of adult respiratory distress syndrome and pulmonary fibrosis. Elucidation of the mechanisms that regulate EGFR residence on the plasma membrane during inflammatory lung conditions is important for identifying potential therapies. We have demonstrated that flagellin phosphorylated EGFR at Ser1047 and induced transient EGFR internalization. In this study, we examined the molecular pathway and effect of interleukin 1 beta (IL-1ß) on EGFR in alveolar epithelial cells. Treatment of A549 cells with IL-1ß induced the activation of p38 mitogen-activated protein kinase (MAP kinase) and MAP kinase-activated protein kinase-2 (MAPKAPK-2), as well as EGFR phosphorylation at serine 1047. Both MAPKAPK-2 activation and EGFR phosphorylation were inhibited by SB203580, a p38 MAP kinase inhibitor. In addition, MK2a inhibitor (a MAPKAPK-2 inhibitor) suppressed EGFR phosphorylation. Assessment of the biotinylation of cell surface proteins indicated that IL-1ß induced EGFR internalization. Furthermore, long-term treatment of A549 cells with IL-1ß caused morphological changes and loss of cell-cell contact. Moreover, IL-1ß augmented the effect of transforming growth factor beta 1 on the epithelial-mesenchymal transition. These results suggested that IL-1ß regulates EGFR functions and induces morphological changes of alveolar epithelial cells.

Phosphorylation of epidermal growth factor receptor at serine 1047 in cultured lung alveolar epithelial cells by bradykinin B2 receptor stimulation.

Accumulating evidence indicates that epidermal growth factor receptor (EGFR) is desensitized by phosphorylation of serine 1047 (Ser1047). We and other groups have reported that stimulation of a receptor of tumor-necrosis factor α (TNFα) and Toll-like receptor 5 (TLR5) induced the phosphorylation of Ser1047 through activation of p38 mitogen-activated protein kinase (p38 MAPK) in cultured lung alveolar epithelial A549 cells. However, phosphorylation of EGFR at Ser1047 by stimulation of any G-protein coupled receptors (GPCRs) has not been reported in any cultured cells. In the present study, we first confirmed that A549 cells expressed bradykinin (BK) B2 receptor, and then, we examined whether BK treatment of A549 cells activated MAPKs and induced the phosphorylation of EGFR at Ser1047. Immunoblotting analysis and reporter gene assays indicated that BK activated the pathways of extracellular signal-regulated kinase (ERK) and p38 MAPK. Inhibitor studies suggested that Gq/11 was mainly involved in the activation of ERK and p38 MAPK. We found that stimulation of the BK B2 receptor, but not the BK B1 receptor, induced phosphorylation of EGFR at Ser1047. Pharmacological experiments indicated that both ERK and p38 MAPK were involved in the phosphorylation of EGFR. These results strongly suggested that BK regulates EGFR functions in lung alveolar epithelial cells. In addition, we found that BK treatment increased the mRNA level of dual specificity MAPK phosphatase 5 (DUSP5) in an ERK-dependent manner, which suggested that a negative feedback mechanism of ERK existed in the cells.

[Current Situation Survey of the Measures to Prevent Medication Errors in the Operating Room: Report of the Japan Society of Anesthesiologists Safety Commission Working Group for Consideration of Recommendations for Color Coding of Prepared Syringe Labels for Prevention of Medication Errors].

BACKGROUND: In the case of medication errors which are among the more frequent adverse events that occur in the hospital, there is a need for effective measures to prevent incidence. According to the Japan Society of Anesthesiologists study "Drug incident investigation 2005-2007 years", "Error of a syringe at the selection stage" was the most frequent (44.2%). The status of current measures and best practices implemented in Japanese hospitals was the focus of a subsequent investigation. METHODS: Representative specialists in anesthesiology certified hospitals across the country were surveyed via a questionnaire sampling that lasted 46 days. Investigation method was via the Web with survey responses anonymous. RESULTS: With respect to preventive measures implemented to mitigate risk of medication errors in perioperative settings, responses included: incident and accident report (215 facilities, 70.3%), use of pre-filled syringes (180 facilities, 58.8%), devised the arrangement of dangerous drugs (154 facilities, 50.3%), use of the product with improper connection preventing mechanism (123 facilities, 40.2%), double-check (116 facilities, 37.9%), use of color barreled syringe (115 facilities, 37.6%), use of color label or color tape (89 facilities, 29.1%), presentation of medication such as placing the ampoule or syringe on a tray by dividing color code for drug class on a tray (54 facilities, 17.6%), the discontinuance of handwritten labels (23 facilities, 7.5%), use of a drug verification system that uses bar code (20 facilities, 6.5%), and facilities that have not implemented any means (11 facilities, 3.6%), others not mentioned (10 facilities, 3.3%), and use of carts that count/account the agents by drug type and record selection and number picked automatically (6 facilities, 2.0%). Drug name identification affixed to the syringe via perforated label torn from the ampoule/vial, etc. (245 facilities, 28.1%), handwriting directly to the syringe (208 facilities, 23.8%), use of the attached label (like that comes with the product) (187 facilities, 21.4%), handwriting on the plain tape (87 facilities, 10.0%), printing labels (62 facilities, 7.1%), printed color labels (44 facilities, 5.0%), handwriting on the color tape (27 facilities, 3.1%), machinery for printing the drug name by scanning bar code of the ampoule, etc.(10 facilities, 1.1%), others (3 facilities, 0.3%), no description on the prepared drug (0 facilities, 0%). The awareness of international standard color code, such as by the International Organization for Standardization (ISO), was only 18.6%. CONCLUSIONS: Targeting anesthesiology certified hospitals recognized by the Japan Society of Anesthesiologists, the result of the survey on the measures to prevent medication errors during perioperative procedures indicated that various measures were documented in use. However, many facilities still use hand written labels (a common cause for errors). Confirmation of the need for improved drug name and drug recognition on syringe was documented.

Stimulation of Cell Migration by Flagellin Through the p38 MAP Kinase Pathway in Cultured Intestinal Epithelial Cells.

Toll-like receptor 5 (TLR5) is a receptor for flagellin and is present on the basolateral surface of intestinal epithelial cells. However, the pathological roles of TLR5 in intestinal epithelial cells are not clear at present. In previous reports, we demonstrated that treatment of cultured alveolar epithelial cells with flagellin activated the p38 mitogen-activated protein kinase (MAPK) pathway and enhanced epithelial-mesenchymal transition induced by transforming growth factor beta 1 (TGF-ß1). In translating our findings in alveolar epithelial cells to intestinal epithelial cells, we found that both flagellin and TGF-ß1 activated p38 MAPK and its downstream protein kinase, MAPK-activated protein kinase-2 (MAPKAPK-2) in an IEC-6 intestinal epithelial cell line. The phosphorylation of HSP27, one of the substrates for MAPKAPK-2, was also increased. TGF-ß1 increased the protein level of α-smooth muscle actin (αSMA), and flagellin enhanced the effect of TGF-ß1. A wound healing assay revealed that flagellin and TGF-ß1 stimulated the migration of cells. SB203580, an inhibitor of p38 MAPK, and an inhibitor of MAPKAPK-2 inhibited flagellin-stimulated migration. These results suggested that TLR5 is involved in the migration of intestinal epithelial cells through activation of the p38 MAPK pathway.

Dietary supplementation with sodium nitrite can exert neuroprotective effects on global cerebral ischemia/reperfusion in mice.

BACKGROUND: Nitrite-derived NO protects against middle cerebral artery occlusion in mice. We developed a new mouse model of global cerebral ischemia and reperfusion (GCI/R) involving reversible occlusion of the major vessels from the aortic arch supplying the brain, and investigated neuroprotection with dietary sodium nitrite supplementation against GCI/R injury. METHODS: Mice received drinking water with (nitrite group) or without (control group) sodium nitrite (2 mM) for 5 days and underwent 3-min GCI/R by reversible occlusion of major vessels from the aortic arch (i.e., brachiocephalic, left common carotid, and left subclavian artery). Survival rates and neurological function scores were evaluated for up to 5 days after GCI/R. Histopathological studies were performed to detect neurological degeneration and caspase-3 activation in serial hippocampal sections. RESULTS: In the control group, 17/30 mice (57 %) survived 5 days after 3-min GCI/R, whereas in the nitrite group 25/30 mice (83 %) survived (p < 0.05). The neurological score at 5 days after GCI in control group was significantly higher than in the nitrite group. Cerebral blood flow (CBF) during GCI was significantly higher in the nitrite group than in the control group, while MABP did not differ significantly between groups. Degenerative changes and caspase-3 activation in hippocampal sections after GCI were observed in the control group but not in the nitrite group. Pretreatment with the NO scavenger c-PTIO abolished the neuroprotective effects of sodium nitrite. CONCLUSIONS: Sodium nitrite supplementation attenuated mortality and neurological impairment after 3-min GCI in mice; an effect likely mediated via vascular mechanisms involving NO.

Differential regulation of epidermal growth factor receptor by hydrogen peroxide and flagellin in cultured lung alveolar epithelial cells.

In previous studies, we found that stimulation of Toll-like receptor 5 (TLR5) by flagellin induced the activation of mitogen-activated protein kinase (MAPK)-activated protein kinase-2 (MAPKAPK-2) through activation of the p38 MAPK pathway in cultured alveolar epithelial A549 cells. Our studies strongly suggested that MAPKAPK-2 phosphorylated epidermal growth factor receptor (EGFR) at Ser1047. It has been reported that phosphorylation of Ser1047 after treatment with tumor necrosis factor α (TNFα) induced the internalization of EGFR. In the present study, we first found that treatment of A549 cells with hydrogen peroxide induced the activation of MAPKAPK-2 and phosphorylation of EGFR at Ser1047 within 30 min. This was different from flagellin treatment because hydrogen peroxide treatment induced the phosphorylation of EGFR at Tyr1173 as well as Ser1047, indicating the activation of EGFR. We also found that KN93, an inhibitor of CaM kinase II, inhibited the hydrogen peroxide-induced phosphorylation of EGFR at Ser1047 through inhibition of the activation of the p38 MAPK pathway. Furthermore, we examined the internalization of EGFR by three different methods. Flow cytometry with an antibody against the extracellular domain of EGFR and biotinylation of cell surface proteins revealed that flagellin, but not hydrogen peroxide, decreased the amount of cell-surface EGFR. In addition, activation of extracellular signal-regulated kinase by EGF treatment was reduced by flagellin pre-treatment. These results strongly suggested that hydrogen peroxide activated the p38 MAPK pathway via activation of CaM kinase II and that flagellin and hydrogen peroxide regulate the functions of EGFR by different mechanisms.

[Intraoperative crisis and surgical Apgar score].

Intraoperative crisis is an inevitable event to anesthesiologists. The crisis requires effective and coordinated management once it happened but it is difficult to manage the crises properly under extreme stressful situation. Recently, it is reported that the use of surgical crisis checklists is associated with significant improvement in the management of operating-room crises in a high-fidelity simulation study. Careful preoperative evaluation, proper intraoperative management and using intraoperative crisis checklists will be needed for safer perioperative care in the future. Postoperative complication is a serious public health problem. It reduces the quality of life of patients and raises medical cost. Careful management of surgical patients is required according to their postoperative condition for preventing postoperative complications. A 10-point surgical Apgar score, calculated from intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate, is a simple and available scoring system for predicting postoperative complications. It undoubtedly predicts higher than average risk of postoperative complications and death within 30 days of surgery. Surgical Apgar score is a bridge between proper intraoperative and postoperative care. Anesthesiologists should make effort to reduce the postoperative complication and this score is a tool for it.

Desensitization by different strategies of epidermal growth factor receptor and ErbB4.

Four transmembrane tyrosine kinases constitute the ErbB protein family: epidermal growth factor receptor (EGFR) or ErbB1, ErbB2, ErbB3, and ErbB4. In general, the structure and mechanism of the activation of these members are similar. However, significant differences in homologous desensitization are known between EGFR and ErbB4. Desensitization of ligand-occupied EGFR occurs by endocytosis, while that of ErbB4 occurs by selective cleavage at the cell surface. Because ErbB4 is abundantly expressed in neurons from fetal to adult brains, elucidation of the desensitization mechanism is important to understand neuronal development and synaptic functions. Recently, it has become clear that heterologous desensitization of EGFR and ErbB4 are induced by endocytosis and cleavage, respectively, similar to homologous desensitization. It has been reported that heterologous desensitization of EGFR is induced by serine phosphorylation of EGFR via the p38 mitogen-activated protein kinase (p38 MAP kinase) pathway in various cell lines, including alveolar epithelial cells. In contrast, the protein kinase C pathway is involved in ErbB4 cleavage. In this review, we will describe recent advances in the desensitization mechanisms of EGFR and ErbB4, mainly in alveolar epithelial cells and hypothalamic neurons, respectively.

[Anesthetic management of intra-aortic balloon occlusion (IABO) for seven cases of placenta accreta--a six year experience at our institute].

We studied retrospectively amount of bleeding, clamping time, and the presence or absence of ischemia-reperfusion injury in all seven cases of IABO performed for placenta accreta from 2007 to 2012 at our hospital. We also examined rSO2 change before and after clamping in four cases in which lower-limb rSO2 monitoring was performed with NIRS (near-infrared spectroscopy). There was no case suspected of ischemia-reperfusion injury during and after clamping with the amount of bleeding around 1,580-10,973 ml (mean 4,536 ml) and clamping time of 10-83 min (mean 44 min). No significant decrease was observed in lower-limb rSO2 with 73.5 ± 5.9% before clamping and 70.8 ± 5.6% (mean ± SD) after clamping.

[Case report : usefulness of the airwayscope for difficult intubations in a pediatric patients with Coffin-Siris syndrome].

We experienced management of general anesthesia in a patients with Coffin-Siris syndrome (CS syndrome) which is an autosomal dominant disorder characterized by mental retardation, growth failure, hypoplasia of the fifth finger's distal phalanx and limb, and syndrome-specific facial appearance. Anesthesia was induced by sevoflurane by mask. After obtaining muscle relaxation by rocuronium, laryngoscopy by Machintosh #2 failed to reveal the vocal cord. However, the vocal cord was revealed by AirwayScope (AWS) for the pediatrics and then tracheal intubation was successful. Surgical procedures and anes-thetic management were performed uneventfully. This case demonstrates usefulness of AWS in pediatric patients with difficult intubation.

Long-term treatment with san'o-shashin-to, a kampo medicine, markedly ameliorates cardiac ischemia-reperfusion injury in ovariectomized rats via the redox-dependent mechanism.

BACKGROUND: Hormone replacement therapy has failed to reduce ischemic cardiovascular events in climacteric women. To explore alternative therapy, we examined whether san'o-shashin-to (TJ-113), a kampo medicine, ameliorates cardiac ischemia-reperfusion (IR) injury in a climacteric rat model. METHODS AND RESULTS: Cardiac function and infarct size after IR were significantly exacerbated in ovariectomized rats as compared with sham-operated rats, whereas long-term treatment with a clinical dosage of TJ-113 for 4 weeks markedly improved these functional and morphological changes. Myocardial inducible nitric oxide synthase (iNOS) expression and peroxynitrite levels were significantly higher in ovariectomized rats compared with sham-operated rats, and long-term TJ-113 treatment significantly reduced these oxidative changes. Furthermore, myocardial manganese superoxide dismutase (Mn-SOD) activity was significantly lower in ovariectomized than in sham-operated rats, and long-term TJ-113 treatment significantly restored antioxidant activity. Importantly, those beneficial actions of TJ-113 were significantly inhibited by the estrogen receptor antagonist, fulvestrant, and the phytoestrogen, emodin, a TJ-113 ingredient, mimicked the actions of TJ-113, suggesting involvement of emodin in the effects of TJ-113. CONCLUSIONS: These results provide the first evidence that long-term treatment with a clinical dosage of TJ-113 markedly ameliorates cardiac IR injury in ovariectomized rats via inhibition of iNOS expression, suppression of peroxynitrite formation, and restoration of Mn-SOD activity. TJ-113 may be a novel therapeutic option in the treatment of ischemic heart disease in climacteric women.

[Utility of a bronchoscope and a gum elastic bougie for nasal intubation in a patient with a history of transsphenoidal surgery].

A 39-year-old man with a history of transsphenoidal surgery was scheduled for sagittal split ramus osteotomy. Nasal intubation was successfully performed using a bronchoscope (BF) and a gum elastic bougie (GB). inserted using a BE The BF was then replaced with a GB. We widened his nasal cavity using the nasal airway. Finally, intubation was performed with an endotracheal tube (7.0 mm) using a GB and a Macintosh laryngoscope. Thus, BF and GB could be safely used for nasal intubation in a patient with a history of transsphenoidal surgery.

Phosphorylation of epidermal growth factor receptor at serine 1047 by MAP kinase-activated protein kinase-2 in cultured lung epithelial cells treated with flagellin.

It has been reported that tumor necrosis factor α (TNFα) activated the p38 MAP kinase pathway, followed by phosphorylation of epidermal growth factor receptor (EGFR) at serine 1047 (Ser1047). Although the phosphorylation of Ser1047 reportedly induced an internalization of EGFR, a protein kinase responsible for the phosphorylation has not been elucidated. In the present study, we found that treatment with flagellin of A549 cells, an alveolar epithelial cell line, induced the activation of p38 MAP kinase, followed by phosphorylation of EGFR at Ser1047. The phosphorylation was strongly inhibited by SB203580, an inhibitor of p38 MAP kinase. The flagellin treatment activated MAP kinase-activated protein kinase-2 (MAPKAPK-2), a protein kinase downstream of p38 MAP kinase, and MK2a inhibitor, an inhibitor of MAPKAPK-2, inhibited the flagellin-induced phosphorylation of EGFR at Ser1047. Unlike the flagellin treatment, the TNFα treatment induced the phosphorylation of EGFR at both Ser1047 and Tyr1173. SB203580 and MK2a inhibitor strongly inhibited the phosphorylation of Ser1047 but not Tyr1173 in EGFR. Finally, bacterially expressed and activated MAPKAPK-2 phosphorylated EGFR at Ser1047 in vitro. These results suggest that flagellin regulates the residence time of EGFR on the plasma membrane and thus the signaling of EGFR through phosphorylation of Ser1047 by MAPKAPK-2.

Induction of epithelial-mesenchymal transition by flagellin in cultured lung epithelial cells.

Toll-like receptor 5 (TLR5) recognizes bacterial flagellin and activates host inflammatory responses, mainly through activation of the NF-κB pathway. Although pulmonary fibrosis occurs in some cases of lung infection by flagellated bacteria, the pathological roles of TLR5 stimulation in pulmonary fibrosis have yet to be elucidated. In the present study, we first confirmed that flagellin activated the NF-κB pathway in cultured A549 alveolar epithelial cells. Next, we examined the types of genes whose expression was modulated by flagellin in the cells. Microarray analysis of gene expression indicated that flagellin induced a change in gene expression that had a similar trend to transforming growth factor-ß1 (TGF-ß(1)), a key factor in the induction of epithelial-mesenchymal transition (EMT). Biochemical analysis revealed that TGF-ß(1) and flagellin increased the level of fibronectin protein, while they reduced the level of E-cadherin protein after 30 h of treatment. Interestingly, simultaneous treatment with TGF-ß(1) and flagellin significantly augmented these EMT-related changes. Flagellin strongly activated p38 MAP kinase, and the activation was sustained for longer than 30 h. SB203580, an inhibitor of p38 MAP kinase, inhibited the upregulation of fibronectin by both flagellin and TGF-ß(1). Simultaneous treatment with TGF-ß(1) and flagellin augmented the activation of p38 MAP kinase by TGF-ß(1) or flagellin alone. These results strongly suggest that flagellin cooperates with TGF-ß(1) in the induction of EMT in alveolar epithelial cells.

[Utility of target controlled infusion technique for deciding the fentanyl infusion rate for post-cholecystectomy pain management in a patient on anticoagulant therapy].

The fentanyl infusion rate was controlled by employing a target controlled infusion (TCI) technique under anticoagulant therapy for postoperative pain management. A 59-year-old woman with atrial fibrillation and mitral stenosis was scheduled for open cholecystectomy. Heparin was continuously infused for anticoagulant therapy. Sevoflurane and remifentanil were used for induction and maintenance of anesthesia. At completion of the operation, her consciousness was checked and the endotracheal tube was then removed under fentanyl TCI (effect-site concentration: Ce = 2.0 ng x ml(-1)). In this case, the spontaneous breathing rate was stable (10-12 x min(-1)) under fentanyl TCI. She had no complaints of pain(pain at rest: VAS 20 mm). The breathing rate in this case provided indication for postoperative pain management. The TIVAtrainer simulation makes the exchange from TCI infusion to continuous infusion easy. And the spontaneous breathing monitoring is useful for postoperative pain measurement of laparotomy cases.