Intrathecal morphine exacerbates paresis with increasing muscle tone of hindlimbs in rats with mild thoracic spinal cord injury but without damage of lumbar α-motoneurons.

Adverse effects of morphine on locomotor function after moderate to severe spinal cord injury (SCI) have been reported; however, the effects after mild SCI without damage of lumbar α-motoneurons have not been investigated. We investigated the effects of lumbar intrathecal morphine on locomotor function after mild thoracic SCI and the involvement of classic opioid receptor activation. A mild thoracic contusive SCI was induced in adult rats at the T9-T10 spine level under sevoflurane anesthesia. We evaluated the effects of single doses of intrathecal morphine and selective µ-, δ-, and κ-opioid receptor agonists, continuous infusion of intrathecal morphine for 72 hours, and administration of physiological saline on locomotor function and muscle tone in the hindlimbs. The numbers of damaged and total α-motoneurons in the lumbar spinal cord were also investigated. Single doses of morphine aggravated residual locomotor function after SCI but did not affect functional recovery. Single doses of morphine and µ- and δ-opioid receptor agonists significantly aggravated residual locomotor function with increases in muscle tone after SCI, and the effects of the drugs were reversed by naloxone. In contrast, continuous infusion of morphine led to persistent decline in locomotor function with increased muscle tone, which was not reversed by naloxone, but did not increase the number of damaged lumbar α-motoneurons. These results indicate that a single dose of morphine at an analgesic dose transiently increases muscle tone of the hindlimbs via activation of spinal µ- and δ- opioid receptors, resulting in further deterioration of locomotor function in the acute phase of mild SCI. Our results also suggest that an increased dose of morphine with prolonged administration leads to persistent decline in locomotor function with increased muscle tone via mechanisms other than direct activation of classical opioid receptors. Morphine should be used cautiously even after mild SCI.

Incidence of postsurgical pulmonary embolism and deep venous thrombosis: a single-center retrospective observational study.

BACKGROUND: Cancer is a risk factor for perioperative deep venous thrombosis and pulmonary embolism (DVT/PE). However, there is a paucity of data on non-malignant digestive diseases. In this study, we aimed to investigate the incidence of DVT/PE among patients, following surgery for acute appendicitis and other digestive diseases. METHODS: We retrospectively reviewed the records of patients who underwent surgical procedures involving the digestive system between April 2018 and March 2019 attended by anesthesiologists (n = 536). RESULTS: DVT/PE developed in seven patients (7/77, 9.1%, 95% confidence interval [CI] 3.7-17.8%) after surgery for acute appendicitis, and in six patients (6/83, 7.2%, 95%CI 2.7-15.1%) after elective surgery for colorectal cancer. Among the acute appendicitis group, six patients (6/30 20.0%) with complicated appendicitis (gangrenous or perforated appendicitis), and one patient (1/47 2.1%) with simple appendicitis showed postoperative DVT/PE. Patients with complicated appendicitis had a higher risk of DVT/PE than those with simple appendicitis with an odds ratio of 11.5 (95%CI 1.3-101.1). CONCLUSIONS: Although patients with acute appendicitis lack three of the risk factors for DVT/PE (cancer, long operative time, and older age), their 95% CI for the incidence of DVT/PE was comparable to that of patients undergoing elective surgery for colorectal cancer. Therefore, caution must be exercised during the perioperative period for preventing DVT/PE.

[Anesthetic management of a morbidly obese patient undergoing laparoscopic right nephrectomy].

A 41-year-old man weighing 196 kg (body mass index of 62.5 kg m2) with renal cancer was scheduled for laparoscopic right nephrectomy. On the day before surgery, we confirmed the intraoperative patient position with the patient and medical staff to prevent neurological deficit during the intraoperative period. For postoperative analgesia and prevention of respiratory complications, an epidural catheter was inserted under radiography and ultrasound guidance. Difficult airway was anticipated, and we attempted awake intubation in the left lateral position with Airwayscope (AWS). The vocal cord was visualized with AWS; however, because of his small oral cavity, we could not place the Intlock of AWS to insert the tracheal tube appropriately. Using a flexible fiberoptic bronchoscope under AWS guidance, the trachea was intubated. During neumoperitoneum at 12 mmHg, mechanical ventilation was achieved without hypercapnia, hypoxia or elevated airway pressure, with rate of 12 min-1, FIO2 of 0.6, PIP of 25 cmH2O and PEEP of 8 cmH2O. The surgery was completed and his trachea was extubated in the operating room. He did not develop any perioperative complications and was discharged on the 10th day after the surgery.

[Anesthesia for a hemodialysis patient with HIT undergoing CABG using argatroban].

Anesthetic Management of CABG in a Hemodialysis patient complicated by heparin-induced thrombocytopenia (HIT) type II is one of the different procedures in hemodialysis patients using heparin. An 81-year-old man receiving hemodialysis complicated by HIT type II was scheduled for coronary artery bypass grafting (CABG). Anesthesia was induced and maintained with propofol, remifentanil and rocuronium. During artificial cardiopulmonary bypass, activated clotting time (ACT) was maintained above 300 sec by in initial 0.1 mg x kg(-1) and subsequent 2.0-7.0 microg x kg(-1) x min(-1) doses of argatroban; a direct thrombin inhibitor. Immediately after the completion of the external cardiopulmonary circulation, continuous infusion of argatroban was discontinued. Seven hours later ACT was restored to the preoperative level. Both intra and postoperative courses were uneventful.

[Anesthetic management of patients with neuronal ceroid lipofusucinosis].

Neuronal ceroid lipofuscinoses (NCL) are in a group of autosomal recessive inherited neurodegenerative diseases characterized by the accumulation of autofluorescent storage material in many cell types. Clinical manifestations of NCL are progressive mental and motor deterioration, seizures, and visual loss. We report anesthetic management for two siblings with NCL. Placement of percutaneous endoscopic gastrostomy tubes were scheduled for both 31-year-old woman and her 29-year-old sister with NCL. Although they were treated with several anticonvulsants, the grand mal and myoclonic seizures persisted. Anesthesia was maintained with propofol, nondepolarizing muscle relaxant, and narcotics. They showed no complications except for mild hypothermia during anesthesia. However, BIS index fluctuated widely during anesthesia in both cases. Their postoperative course was uneventful.

[Effects of percutaneous lidocaine administration and xenon-ray irradiation on post-herpetic neuralgia in liver transplant recipients: a report of three cases].

We report three cases of liver transplant recipients (LTRs) with postherpetic neuralgia (PHN). They were referred to our department because of poor pain control. Repeated percutaneous lidocaine (2%, 15 ml) administration to the site of the pain via an iontophoresis system and xenon-ray irradiation were effective for the three patients. Visual analogue scale for pain decreased significantly and requirements of analgesics diminished considerably during the therapy without serious side effects. PHN is relatively common in LTRs, but treatment options are restricted because of immunosuppressive therapy and hepatic and/or renal dysfunction. However noninvasive frequent iontophoretic administration of lidocaine and xenon-ray irradiation produced satisfactory pain relief for PHN in LTRs.

[Appropriate evaluation of total workload in anesthesia].

Number of cases performed or total anesthesia time is usually used to evaluate workload anesthesiologists. However, each case is different in intensity of anesthetic management and these makes the evaluation difficult. We devised a total workload in anesthesia formula to account for technical, tactical, and physical factors in each case, as well as for number of cases and total anesthesia time. The present study evaluated reasonableness of this formula. We compared number of cases, hours of work, medical treatment fee and the total workload in anesthesia among anesthesiologists who had worked in our hospital in 2001. Each anesthesiologist answered questionnaires regarding number of cases, total anesthesia time, and total workload during 2001. Among anesthesiologists, we found significant differences in number of cases and total anesthesia time and medical treatment fee but no difference in total workload in anesthesia. The anesthesiologists indicated the same trend in their questionnaire responses. Evaluating only number of cases or total anesthetic time or medical treatment fee provides insufficient information to compare anesthesia workload. Our formula is a more appropriate index to quantify workload.