Anaesthetic management of a patient with relapsing polychondritis undergoing laparoscopic surgery.

We describe the anaesthetic management of a patient with relapsing polychondritis who underwent laparoscopic cholecystectomy. We failed to secure a patent airway with a ProSeal laryngeal mask airway, probably because of the deformity of the larynx. The glottis was small and it was only possible to pass a 5.5 mm cuffed endotracheal tube into the trachea. Positive pressure ventilation with 5 cm H2O positive end-expiratory pressure and surgery were safely performed. In relapsing polychondritis, recurrent inflammation and destruction of laryngeal and tracheobronchial cartilage causes airway obstruction, and various sizes of tracheal tubes and other airway manipulation devices should be prepared.

The McCoy laryngoscope, external laryngeal pressure, and their combined use.

The efficacy of the McCoy laryngoscope, external laryngeal pressure, and their combination to improve the laryngoscopic view was evaluated in 219 patients and compared with the Macintosh laryngoscope. An experienced laryngoscopist performed laryngoscopy twice using the Macintosh laryngoscope and the McCoy laryngoscope in a random sequence, and external laryngeal pressure was applied in each laryngoscopy with the laryngoscopist's right hand. The laryngoscopic view obtained was graded on our modified Cormack's method. Without external laryngeal pressure, the McCoy laryngoscope provided a better laryngoscopic view than that obtained by the Macintosh laryngoscope (P < 0.001, signed rank test), but the view was worse than that with the Macintosh laryngoscope under external laryngeal pressure (P < 0.001). The McCoy laryngoscope combined with external laryngeal pressure provided a better view than the Macintosh laryngoscope with external laryngeal pressure (P < 0.001).

"Deep-forehead" temperature correlates well with blood temperature.

PURPOSE: To evaluate the accuracy and precision of "deep-forehead" temperature with rectal, esophageal, and tympanic membrane temperatures, compared with blood temperature. METHODS: We studied 41 ASA physical status 1 or 2 patients undergoing abdominal and thoracic surgery scheduled to require at least three hours. "Deep-forehead" temperature was measured using a Coretemp thermometer (Terumo, Tokyo, Japan). Blood temperature was measured with a thermistor of a pulmonary artery. Rectal, tympanic membrane, and distal esophageal temperatures were measured with thermocouples. All temperatures were recorded at 20 min intervals after the induction of anesthesia. We considered blood temperature as the reference value. Temperatures at the other four sites were compared with blood temperature using correlation, regression, and Bland and Altman analyses. We determined accuracy (mean difference between reference and test temperatures) and precision (standard deviation of the difference) of 0.5 degrees C to be clinically acceptable. RESULTS: "Deep-forehead" temperature correlated well with blood temperature as well as other temperatures, the determination coefficients (r2) being 0.85 in each case. The bias for the "deep-forehead" temperature was 0.0 degrees C, which was the same as tympanic membrane temperature and was smaller than rectal and esophageal temperatures. The standard deviation of the differences for the "deep-forehead" temperature was 0.3 degrees C, which was the same as rectal temperature. CONCLUSIONS: We have demonstrated that the "deep-forehead" temperature has excellent accuracy and clinically sufficient precision as well as other three core temperatures, compared with blood temperature.

Histochemical investigation of ß-glucuronidase in culture cells and regenerated plants of Scutellaria baicalensis Georgi.

Strong activity of ß-glucuronidase first appeared in the epidermal and glandular hair cells of leaf primordia regenerated from callus of Scutellaria baicalensis Georgi. Leaf primordia matured rapidly in culture to form shoots within 1 month in which both the mesophyll cells and the glandular hairs were deeply stained. Leaves predominantly accumulated ß-glucuronidase in both glandular hair cells and mesophyll cells. ß-Glucronidase activity in leaves was higher in the summer and decreased in the winter. The stem section collected in the summer had a different ß-glucuronidase distribution pattern from that of the root in that in the former strong activity appeared in the periderm cells and collenchyma cells which was decreasingly dispersed into the phloem layer cells. In the winter, ß-glucronidase activity decreased compared to that in summer. It can be argued that the distribution of ß-glucuronidase in this plant is closely linked with the defense against pathogens: it is a starting key enzyme which may act together with the flavonoids, which play an important role as a proton donor for the detoxification metabolism of H2O2.

[Clinical evaluation of the Terumo ES H51 semi-automatic blood pressure measuring device].

The relative accuracy of a semi-automated portable blood pressure (BP) measuring device, Terumo ES-H51, which is based on the auscultatory method, was assessed by comparison with simultaneous sphygmomanometric measurement on 48 patients, including hypertensive patients. During rest, mean differences and limits of agreement (mean +/- 2SD) were -1.3 mmHg, -7.9 and 5.3 mmHg, respectively for systolic BP, and -0.2 mmHg, -8.4 and 8.0 mmHg, respectively for diastolic BP. Although the differences between ES-H51 and sphygmomanometric measurement did not increase with repeated measurements or with changes of BP during the induction of anesthesia, blood pressure measurement by ES-H51 was sometimes impossible or erroneous during upper abdominal surgeries in 5 patients. We concluded that ES-H51 has satisfactory accuracy, and is suitable for blood pressure assessment during the peri-operative period but not during surgery.

[Relative accuracy of Thermoscan PRO-1 in patients under general anesthesia].

The relative accuracy of Thermoscan PRO-1 (Thermoscan, USA), an infrared ear thermometer, in an unadjusted mode was examined in 21 patients under general anesthesia, using the esophageal and tympanic membrane temperatures as the reference values. The correlation coefficient between the temperature measured by Thermoscan PRO-1 and the esophageal temperature, and that between the temperature measured by Thermoscan PRO-1 and the tympanic membrane temperature, were 0.953 and 0.942, respectively (P < 0.01). The "limits of agreement" between the temperature measured by Thermoscan PRO-1 and esophageal temperature, and between the temperature measured by Thermoscan PRO-1 and tympanic membrane temperature, were -0.5-0.4 degrees C and -0.5-0.5 degrees C, respectively. We conclude that Thermoscan PRO-1 is sufficiently reliable for monitoring body temperature during surgery.

[Anesthetic management of a patient with Bernard-Soulier syndrome].

Bernard-Soulier syndrome (BSS) is a hereditary hemorrhagic disease characterized by prolonged bleeding time due to abnormal platelet aggregation and giant platelets. Transfusion of platelet-rich plasma is the only treatment available for the hemorrhagic episodes in patients with this disease. A 20-year-old female with BBS was scheduled for sagittal osteotomy of the mandibular rami under general anesthesia. Anesthesia was induced with fentanyl and diazepam, and was maintained with nitrous oxide, fentanyl, and 0.5% enflurane. No exacerbation of the bleeding tendency was observed during or after the surgery. We consider that the use of halothane should be avoided in patients with BBS because it may inhibit the aggregation of platelets and prolong the bleeding time.

[Relative accuracy and precision of two non-invasive thermometry systems].

The relative accuracy and precision of the two non-invasive thermometry systems, FirstTemp (Intelligent Medical Systems, USA), an infrared tympanic thermometer, and CTM-205 (Terumo, Japan), a newly developed deep body thermometry system, were evaluated in 32 patients undergoing various surgeries under general anesthesia using esophageal temperature as the reference value. The "limits of agreement (mean difference +/- 2SD)" of the "core" temperature measured by FirstTemp and esophageal temperature was 0.4 +/- 0.5 degrees C, and was larger (P < 0.01) than those between rectal temperature and esophageal temperature (0.2 +/- 0.7 degrees C), between tympanic membrane temperature and esophageal temperature (-0.1 +/- 0.4 degrees C), and between "forehead deep body temperature" measured by CTM-205 and esophageal temperature (-0.2 +/- 0.7 degrees C). The "limits of agreement" between "forehead deep body temperature" and esophageal temperature did not differ from that between tympanic membrane temperature and esophageal temperature. The repeatability of the measurement by FirstTemp was good; the difference between paired measurement values was 0 +/- 0.2 degrees C (mean +/- 2SD). We conclude that the relative accuracy and precision of the two systems are still not sufficient for monitoring body temperature during general anesthesia.

Effects of surgical site and inspired gas warming devices on body temperature during lower abdominal and thoracic surgery.

To evaluate the effects of surgical site and inspired gas warming and humidifying devices on body temperature, we studied rectal, tympanic membrane, and esophageal temperature changes in 48 patients. The patients were divided into 4 groups (n = 12), according to surgical site, lower abdominal surgery and thoracic surgery, and according to the warming device used, heat and moisture exchanger (ThermoVent 600) and heated humidifier (Cascade 1). The heated humidifier was controlled to warm inspired gases to about 35 degrees C. All body temperatures fell significantly during surgery. There was no difference in the tympanic membrane and esophageal temperature declines between the two surgical sites, but the decline in rectal temperature was larger in the lower abdominal surgery than in the thoracic surgery. At the end of surgery, all temperatures returned to the value before surgery, and the rectal and tympanic membrane temperatures even exceeded them. There was no difference between the effects of the ThermoVent 600 and Cascade 1. These results suggest that rectal temperature is influenced by the ambient temperature during lower abdominal surgery and that warming and humidifying devices for inspired gases do not prevent, but can restore the decline in body temperature during lower abdominal and thoracic surgery. The heated humidifier showed no advantage over the heat and moisture exchanger in our study.

Structure of the [2Fe-2S] ferredoxin I from the blue-green alga Aphanothece sacrum at 2.2 A resolution.

Crystals of a [2Fe-2S] ferredoxin (Fd) I with a relative molecular mass of 10,480 were obtained from the blue-green alga Aphanothece sacrum. Each asymmetric unit of the crystal contains four molecules. An electron density map calculated by the single isomorphous replacement method with the anomalous dispersion at 2.5 A resolution was refined by averaging the four molecules in the asymmetric unit. Positional and isotropic thermal parameters for the non-hydrogen atoms of the four molecules and 158 water molecules were refined to an R-factor (R = sigma[Fo-Fc[/sigma Fo) of 0.23 by the restrained least-squares method. The estimated root-mean-square (r.m.s.) error for the atomic positions is 0.3 A. The r.m.s. deviations of equivalent C alpha atoms of the asymmetric-unit molecules superposed by the least-squares method average 0.35 A. The Fd molecule has a structure like the beta-barrel in the molecule of the [2Fe-2S] Fd from Spirulina platensis. A [2Fe-2S] cluster is bonded covalently to the protein molecule by four Fe-S, in which three of the Fe-S bonds are in a loop segment from position 38 to 47. The hydrophobic core inside the beta-barrel is formed by seven conservative residues: Val15, Val18, Ile24, Leu51, Ile74, Ala79 and Ile87. The molecular surface around Tyr23, Tyr80 and the active center may interact with ferredoxin-NADP+ reductase. One of the two iron atoms of the [2Fe-2S] cluster should be more easily reduced than the other because of differences in the hydrogen-bonding scheme and the hydrophobicity around the atoms.

Responses to barbiturates of isolated dog cerebral and mesenteric arteries contracted with KCl and prostaglandin F2 alpha.

In helical strips of dog cerebral and mesenteric arteries previously contracted with KCl or prostaglandin F2 alpha (PGF2 alpha), the addition of pentobarbital (10(-5) to 10(-3) mol.l-1) caused dose-related relaxation, whereas thiamylal and thiopental in a low concentration (10(-5) to 10(-4) mol.l-1) caused further contraction and in a high concentration (10(-3) mol.l-1) profound relaxation. Thiobarbiturate-induced contractions were greater in mesenteric than in cerebral arteries previously contracted with PGF2 alpha. In cerebral and mesenteric arteries exposed to Ca(++)-free media for 60 min and treated with KCl or PGF2 alpha, reintroduction of Ca++ produced a transient contraction, a transient relaxation and a persistent contraction. The Ca(++)-induced persistent contraction was attenuated by pretreatment with pentobarbital (10(-4) to 10(-3) mol.l-1) and thiamylal (10(-3) mol.l-1); the attenuation was greater in arteries treated with KCl than with PGF2 alpha. The Ca(++)-induced contractions of mesenteric artery treated with PGF2 alpha were potentiated by 10(-4) mol.l-1 thiamylal. It is concluded that pentobarbital possesses only a vasodilator effect, whereas thiamylal and thiopental have both constrictor and dilator effects on vascular smooth muscle. The vasodilator effect of barbiturates is associated in part with inhibition of transmembrane influx of Ca++; the inhibition is more predominant on the influx evoked by KCl-induced depolarization than by a stimulation of PGF2 alpha receptors. Thiamylal in low concentrations appears to enhance Ca++ influx through a receptor-operated Ca++ channel for PGF2 alpha.

[Anesthesia for Shy-Drager syndrome; effects of elastic bandage, phenylephrine, and IPPV].

A 57-year-old man with Shy-Drager syndrome underwent plastic surgery for decubitus on the buttocks under general anesthesia. Before induction of anesthesia, an elastic bandage was applied to the legs, and its effects were examined by raising the upper body. The fall in mean blood pressure decreased from 49% to 39%, and the symptoms of cerebral hypoxia disappeared. However, the induction of anesthesia with 5 mg diazepam, 0.05 mg fentanyl, and 100 mg thiamylal reduced blood pressure abruptly from 150/88 mmHg to 95/68 mmHg. Continuous infusion of phenylephrine was then started, and blood pressure became stable at around 150/90 mmHg. In this state, IPPV did not reduce the blood pressure in the supine position, and did not intensify its fall when the upper body was raised. Anesthesia was maintained with nitrous oxide 70% in oxygen, fentanyl and pancuronium. During the surgery, ventilation was controlled, and phenylephrine was infused at the rate of 5-15 micrograms.min-1 to maintain systolic blood pressure above 100 mmHg. Phenylephrine was infused during the two postoperative days, because blood pressure fell whenever the patient's posture was changed to prevent pressure on the operative site.