[Analgesic efficacy and clinical safety of intraperitoneal instillation combined with rectus sheath block using ropivacaine for pain relief after laparoscopic gynecological surgery].

BACKGROUND: The aim of this study was to evaluate the analgesic efficacy and safety of rectus sheath block combined with intraperitoneal instillation using two doses of ropivacaine in patients undergoing laparoscopic gynecological surgery. METHODS: Altogether 53 consenting women were randomized to receive intraperitoneal infiltration with 0.25% ropivacaine or 0.5% ropivacaine followed by rectus sheath block with 0.375% ropivacaine. The outcomes of clinical safety were measured using plasma concentration of local anesthetics and occurrence of toxic symptoms. The analgesic efficacy was assessed using numerical rating scales for pain and morphine consumption up to 24 hours after surgery. RESULTS: Patients' baseline characteristics, surgical factors, and analgesic outcomes were comparable between the two groups. Although peak plasma concentration of ropivacaine was significantly higher in patients receiving 0.5% ropivacaine, none of analyzed concentrations was above the toxic ones. Besides, no patients showed any symptoms of local anesthetic toxicity. CONCLUSIONS: The present study showed that the combination of rectus sheath block with intraperitoneal instillation of ropivacaine was safe and potent enough to relieve pain after laparoscopic surgery.

[Case of Rh (-) patient's right lobectomy of the liver with massive hemorrhage evading allogeneic blood transfusion by hemodilutional autologous blood transfusion].

A 44-year-old man (ASA-PS 1) underwent right lobectomy of the liver under total intravenous anesthesia with propofol, remifentanil, ketamine and rocuronium. In order to evade allogeneic blood transfusion, 1,200 g of the patient's blood was taken and hemodilution was induced for autologous blood transfusion (HAT) after the induction of anesthesia. As intraoperative blood loss amounted to about 4,000 g, Hb level decreased from 13.6 to 6.2 g x dl(-1). However, as intraoperative hemodynamics was relatively stable with crystalloidal and colloidal transfusion with no ischemic change on ECG and no metabolic acidosis, autologous blood transfusion was withheld. After returning the autologous blood, Hb increased to 9.8 g x dl(-1). Any postoperative complications related to the low Hb level were not recognized. HAT is a useful method to evade or at least decrease the amount of allogeneic blood transfusion by anesthesiologists.

Mild hypercapnia with hyperventilation attenuates recovery from anesthesia in elderly patients.

PURPOSE: Mild hypercapnia with hyperventilation has been reported to significantly decrease recovery time from inhaled anesthesia in young and middle-aged patients. However, its efficacy has not yet been clarified in elderly patients, although delayed emergence can deteriorate their quality of recovery. METHODS: We enrolled 30 elderly patients (≥65 years) and 30 middle-aged patients (45-64 years) who were scheduled for ophthalmic surgery and allocated them to the control or the device group. Anesthesia was maintained with 1.5% sevoflurane. Mild hypercapnic hyperventilation was induced by the ANEclear anesthesia recovery device. The primary outcome was the time from vaporizer shut-off to initial response (eye or mouth opening, nodding, or grasping hand) in elderly patients. The secondary outcomes were the time to extubation and leaving the operating room (OR), the time to reach 50% of the difference between BIS at extubation and vaporizer shut-off (BIS ET50), and interaction between the recovery measures and patient age. RESULTS: The ANEclear significantly reduced the time to initial response, extubation, leaving the OR, and BIS ET50 in both age groups: their means and 95% CI of the ratio of two means (Mean(ANEclear)/Mean(control)) were 0.576 (0.500, 0.660), 0.595 (0.523, 0.673), 0.713 (0.622, 0.812), and 0.547 (0.444, 0.663), respectively, in the elderly group, and 0.717 (0.591, 0.849), 0.723 (0.609, 0.842), 0.855 (0.736, 0.982), and 0.631 (0.463, 0.813), respectively, in the middle-aged group. The recovery measures were shortened equally in both age groups: P values for the interaction were 0.060679, 0.062534, 0.069215, and 0.420061, respectively. CONCLUSIONS: Recovery time was significantly decreased by the ANEclear in the elderly group. This reduction was comparable to the time for middle-aged patients.

Effects of oral rehydration therapy on gastric volume and pH in patients with preanesthetic H2 antagonist.

Recent preanesthetic fasting practice allows patients to take clear fluids up to 2 h before surgery without taking any antacid for the prophylaxis of aspiration pneumonia; this practice is defined as oral rehydration therapy (ORT). It has been reported that with ORT the gastric volume may be significantly lower than that with a standard fasting regimen, although in a standard fasting regimen without preanesthetic antacid, gastric pH and volume values could be critical for causing aspiration pneumonia. In this study we compared gastric fluid status in patients with ORT and those with a standard fasting regimen; patients in both groups received a preanesthetic H(2) antagonist. One hundred and four patients were randomly assigned to either the ORT or standard fasting group, and all were given roxatidine 75 mg 2 h before surgery. After the induction of anesthesia, the gastric contents were collected via a gastric tube to measure gastric volume and pH. Neither gastric volume nor pH differed between the groups (ORT 9.6 ± 8.2 ml and 5.6 ± 1.7, respectively, vs. standard fasting 8.5 ± 6.8 ml and 5.5 ± 1.7, respectively). These data suggest that ORT may not reduce gastric volume in patients receiving a preanesthetic H(2) antagonist.

[Anesthetic management of surgery for a huge renal tumor with the inferior vena cava invasion--application of Vigileo as a hemodynamic monitor].

In anesthetic management of surgery for a huge renal tumor with the inferior vena cava invasion, maintaining circulatory state is one of the key points. Several hemodynamic parameters are required to evaluate the circulatory state, such as central venous oxygen saturation (ScvO2), cardiac output (CO) and direct arterial blood pressure, in addition to routine hemodynamic parameters like heart rate and central venous pressure. Pulmonary artery catheter is considered as a standard apparatus to obtain those parameters; however, the catheter is invasive and may cause possible pulmonary artery damage, cardiac penetration, or severe arrhythmia. Therefore, application of pulmonary artery catheter is a relative contraindication in some cases. We used Vigileo system to obtain similar hemodynamic parameters. This system provided an arterial based pressure-based cardiac output, central venous oxygen saturation, stroke volume variation (SVV) and so on. In the present case, the system was an alternative device to pulmonary artery catheter system.

Time-consumption risk of real-time ultrasound-guided internal jugular vein cannulation in pediatric patients: comparison with two conventional techniques.

To assess the efficacy of three different methods for internal jugular vein (IJV) cannulation in pediatric patients, we conducted a review of patients undergoing cardiovascular surgery over an 11-year period, in which success rates for cannulation and time from induction of anesthesia to cannulation were evaluated. The success rate was better for real-time ultrasound guidance (USG: 90%) than for anatomic landmarks (AL: 76%) or audio-Doppler guidance (ADG: 74%) and the time required was greater for USG (35.0 +/- 13.6 min) than for AL (26.7 +/- 11.2 min) or ADG (29.2 +/- 8.9 min). However, USG resulted in a higher success rate than the other methods with comparable procedure time for smaller-body-weight (<5 kg) patients. Thus real-time USG leads to the highest success rate for IJV cannulation but with a significant time delay, whereas it was the most useful without time delay for the smaller-body-weight subgroup.

[Effectiveness of continuous central venous oxymetry in living-donor liver transplantation with massive bleeding].

In living relative liver transplantation, patients are exposed to enormous stress and multifaced monitors are required to evaluate physiologic status of the patient such as blood volume, electrolytes balance, clotting ability and metabolic status including oxygen consumption. To maintain transplanted liver graft function, an adequate oxygen supply to the graft is one of the most important factors. Central venous oxygen saturation is minimally invasive and one of the most useful monitor to evaluate the oxygen demand and supply balance in the graft. A continuous central venous oximetry (PreSep, Edwards Lifesciences, Tokyo, JAPAN) was used. The use of the oxymetry to evaluate oxygen demand and supply balance in a living relative liver transplantation especially in a case of massive bleeding was very effective.

[Plasma concentration of propofol was 4.4 microg x ml(-1), 4.5 hours after completion of its administration].

Propofol is one of the most commonly used intravenous anesthetic drugs because its distribution, metabolism and excretion are rapid. Recovery from anesthesia using propofol infusion is generally smooth. We have therefore taken this opportunity to report on a case of delayed recovery from anesthesia in a 58-year-old man who underwent removal of a light maxillary sinus mucocele. General anesthesia was performed with propofol 3-7 mg x kg(-1) x hr(-1) associated with intermittent injection of fentanyl, total of 450 microg. He was not obese, and his preoperative liver function was within normal limits. Any intracranial hematomas, brain edema, cerebral infarction, acid-base abnormalities, hypo- and hyperglycemia and hypothermia were not detected in the early postoperative period. The administration of naloxone hydrochloride and flumazenil failed to improve delayed recovery from anesthesia. It was 16 hours after the end of operation and the administration of propofol had been completed before the trachea could be extubated. His plasma concentration of propofol was 4.4 microg x ml(-1), 4.5 hours after administration. In this patient we could not prove a metabolic abnormality with propofol, but it was strongly suspected.

[Difficult respiratory management in a patient with bilateral giant bullae].

We report a case of bilateral giant bullae in a patient with multiple traumas. He had his arm amputated at the shoulder because of a machine accident and admitted to our hospital. Chest X-ray showed right-sided pneumothorax with bilateral giant bullae. Trimming of the stump was performed immediately after the placement of a right chest tube. He gradually developed hypoxia and hypercapnia with acidemia during the operation because of atelectasis due to sputum. Postoperatively, enlargement of right giant bulla led to frequent respiratory failure and he received a bilateral bullectomy through a median sternotomy 3 weeks after the accident. It was difficult to ventilate him due to air leak from the bilateral bulla and SpO2 dropped to below 70% with 100% oxygen. We continued the operation with standby extracorporeal membrane oxygenator (ECMO). Although the operation was finished without ECMO finally, ECMO had better been kept ready during anethesia with giant bullae when life threatening complication may occur at any point.

Anaphylactoid shock in a patient following 5% human serum albumin infusion during off-pump coronary artery bypass grafting.

A 59-year-old diabetic male patient undergoing off-pump coronary artery bypass grafting developed anaphylactoid shock after 5% human serum albumin (HSA) infusion started. During the first anastomosis, blood loss was more than 600 ml, with slightly decreased blood pressure. Therefore, 5% HSA, 250 ml, was infused against hypovolemia. However, as his blood pressure was decreasing continuously during the second anastomosis, another 250 ml of 5% HSA was added. The blood pressure rapidly dropped to 50/30 mmHg after the second 5% HSA administration started. As i.v. phenylephrine and ephedrine were not effective, norepinephrine was infused. Then we found a high cardiac output (10 l x min(-1)) and peak airway pressure (32 cmH(2)O), with a decrease of oxygenation (P/F ratio, 82), and we suspected 5% HSA-caused anaphylactic shock. Therefore, aminophylline was infused to treat bronchoconstriction. These treatments were effective, and the operation was successfully completed. Postoperatively, we noticed that these reactions may have been anaphylaxis, because the patient had a higher serum tryptase level (16.2 ng x ml(-1)) than the reported nonanaphylaxis serum tryptase level (8.23 ng x ml(-1)). HSA is a relatively safe colloid for use as a volume expander, because it has been reported that the risk of anaphylactoid reactions with HSA was much less than that with gelatins and dextrans, and similar to that with starches. However, the present case suggests that severe allergic reactions should be kept in mind with the use of any colloids.

[Central venous oxygen saturation monitoring was useful in two cases of hepatectomy with massive bleeding].

To maintain adequate hepatic oxygen supply during intra-operative period is very important to prevent post-operative liver failure after hepatectomy. One of the most useful monitors is hepatic venous oxygen saturation. In the same way, central venous oxygen saturation can evaluate balance between oxygen supply and demand, and its cannulation is easier and safer than that for hepatic and mixed venous oxygen saturation. Two cases of hepatectomy performed with the monitoring of continuous central venous oxygen saturation using PreSep Central Venous Oximetry Catheter (Edwards Lifesciences) suffered from massive bleeding. For the management of the circulation and organ oxygenation, the monitoring of continuous central venous oxygen saturation was very simple and useful in these cases.

[Accidental use of suxamethonium for general anesthesia in a patient with hereditary hypocholinesterasemia that was not recognized preoperatively].

We experienced an accidental use of suxamethonium for general anesthesia in a 26-year-old woman with hereditary hypocholinesterasemia that had not been recognized preoperatively. The patient was scheduled for total colectomy as her chronic ulcerative colitis could not be controlled with medications. Routine preoperative screening such as blood cell counts, biochemical data, chest x-ray and electrocardiogram were performed but serum cholinesterase (ChE) activity was not measured. As the preoperative patient condition was good with no abnormal history, anesthesia was induced and maintained with propofol, ketamine and fentanyl as usual. For muscle relaxation, suxamethonium was used for tracheal intubation, and vecuronium was used for the maintenance. After surgery, postanesthetic course was uneventful. One year later, as the patient was pregnant and scheduled for cesarean section, the preoperative screening was done. The biological data showed a hypocholinesterasemia without liver dysfunction. Thus, previous medical records of internal medicine were cheked. Surprisingly the record showed hypocholinesterasemia when she was 15 and 21 years of ages. However, as the physicians did not recognize hypocholinesterasemia, they did not inform the patient of it. Why did the patient have no prolonged apnea and emergence after the previous anesthesia? As the surgical time was exceeded 4 hrs, plasma suxamethonium could fortunately be less than its effective concentration at emergence. However, this case strongly suggests us that preoperative screening should be done without any omission. In addition, if serum ChE activity is not examined, use of suxamethonium should be avoided.

[Anesthetic management for patients with Brugada syndrome].

Brugada syndrome should not be neglected in terms of anesthetic management because its perioperative autonomic imbalance may cause ventricular fibrillation and sudden cardiac arrest. Diagnosis of Brugada syndrome is easily made by unique electrocardiographic pattern of right bundle branch block and ST segment elevation in the right precordial leads. Thus the number of patients with Brugada syndrome for anesthetic management tends to increase. We review current concept of anesthetic management for patients with Brugada syndrome including fourteen cases in our institution, two out of which developed VF during operation.

Inhibitory effects of intravenous anaesthetic agents on K(+)-evoked glutamate release from rat cerebrocortical slices. Involvement of voltage-sensitive Ca(2+) channels and GABA(A) receptors.

It is widely accepted that most general anaesthetic agents depress the central nervous system (CNS) by potentiation or activation of the GABA(A) receptor-mediated Cl(-) conductance. These agents also reportedly inhibit voltage-sensitive Ca(2+) channels (VSCCs), thus depressing excitatory transmission in the CNS. However, in this regard there are few functional data at the level of neurotransmitter release. In this study we examined the effects of VSCC antagonists and a range of intravenous anaesthetic agents on K(+)(40 mM)-evoked glutamate release from rat cerebrocortical slices in the absence and presence of the GABA(A) receptor antagonist bicuculline (100 microM). We employed both selective and non-selective VSCC antagonists, the anaesthetic barbiturates thiopental, pentobarbital and phenobarbital, the non-anaesthetic barbiturate barbituric acid, the non-barbiturate anaesthetics alphaxalone, propofol and ketamine and the GABA(A) receptor agonist, muscimol. Glutamate released into the incubation medium was determined by a glutamate dehydrogenase-coupled assay. Omega-agatoxin IV(A) (P-type VSCC), omega-conotoxin MVII(C) (P/Q-type VSCC) and Cd(2+) (non-selective) essentially abolished glutamate release whilst nifedipine (L-type VSCC) and omega-conotoxin GVI(A) (N-type VSCC) reduced release by less than 30%. The concentrations producing 50% of the maximum inhibition (IC(50)) for thiopental, pentobarbital, phenobarbital, alphaxalone, propofol and ketamine were (in microM) 8.3, 22, 112, 6.3, 83 and 120, respectively. Barbituric acid produced a small (about 20%) inhibition. With the exception of ketamine, the IC(50) values for these anaesthetic agents were increased threefold by bicuculline (100 microM). In addition, muscimol significantly inhibited release by 26% with an IC(50) of 1.1 microM. In summary, a range of anaesthetic agents at clinically achievable concentrations inhibit glutamate release and this inhibition of release appears to be due mainly to direct inhibition of P/Q-type VSCCs, although activation of the GABA(A) receptor plays a role in this response.