[A Case of Acute Pulmonary Edema after Open Abdominal Aortic Aneurysm Repair].

A 61-year-old man, who had previously undergone percutaneous coronary intervention (PCI) of the left anterior descending artery (LAD), was scheduled for open abdominal aortic aneurysm repair under general anesthesia. Although the left ventricular (LV) ejection fraction was 63%, diastolic dysfunction was identified (E/A 0.61). The patient received inhalation induction with 5% sevoflurane and an infusion of remifentanil (0.2µg · kg⁻¹ · min⁻¹). Rocuronium (0.6 mg · kg⁻¹) was administered and tracheal intubation was performed. Anesthesia was maintained with air-oxygen- sevoflurane, an infusion of remifentanil, and 700 µg fentanyl administered intravenously. An infusion of fentanyl (25 µg · hr⁻¹) in combination with rectus sheath block was administered for postoperative anal- gesia. Intraoperatively, we used arterial pressure-based cardiac output (CO), stroke volume variation (SVV), and transesophageal echocardiography as a guide for circulatory management The intraoperative net fluid in-out balance was 5,296 ml, and the duration of the procedure was 5.5 hr. The patient was extubated in the operating room because no significant findings were observed on the postoperative chest X-ray, and PaO2/FI02 (P/F) ratio was 405. At the termination of anesthesia, systolic blood pressure increased to 200 mmHg. The hypertension lasted until after extubation, following which SpO2 diminished gradually. And SpO2 was 78% and PaO2 was 56.7 Torr under 8 l of oxygen. A chest X-ray at this time showed pulmonary edema. There were no findings of ischemic heart disease on either ECG or echocardiography. Immediate vasodilator treatment for the hypertension and non-invasive posi- tive pressure ventilation for the hypoxia were commenced. The P/F ratio recovered to 240 by the night of the surgery, and a chest X-ray showed that the pul- monary edema had resolved. The patient was moved out of the ICU on the first day after the surgery. This case highlights the fact that even when LV systolic function is preserved, diastolic dysfunction may occur, leading to pulmonary congestion due to increased afterload.

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.

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.

[Anesthetic management of a patient with Stickler's syndrome].

Stickler's syndrome is an autosomal multisystem disorder accompanying characteristic midface hypoplasia, retromicrognathia, and cleft palate. Mandibular hypoplasia causes difficulties in mask ventilation and endotracheal intubation, especially in infants. A 7-month-old girl diagnosed as Stickler's syndrome was scheduled for the laparoscopic inguinal hernia repair. However, during the direct laryngoscopy for endotracheal intubation, neither the vocal cords nor the epiglottis were visualized. At fifth intubation attempts, the part of the vocal cords was barely visualized, and the tracheal intubation was finaly successful. Anesthesia was maintained with sevoflurane and remifentanil. The patient had an uneventful recovery and was discharged on the second postoperative day without any complications. Sevoflurane and remifentanil allow faster recovery from anesthesia and both have been recommended for patients with difficult tracheal intubation in a patient such as with Stickler's syndrome.

[Breathing pattern and postoperative analgesia at various effect-site concentrations of fentanyl].

BACKGROUND: We investigated how various effectsite concentrations of fentanyl could affect breathing pattern and postoperative analgesia. METHODS: This study enrolled 64 ASA physical status 1 and 2 patients, undergoing elective surgical procedures, including otologic, orthopedic, breast surgery and gynecological laparoscopic procedure. General anesthesia was performed with sevoflurane inhalation and target-controlled infusion for fentanyl. After the surgery, fentanyl was administered by a target-controlled infusion system to maintain one of the effect-site concentrations of fentanyl as follows ; 0.5, 0.8, 1.0, 1.2, 1.5, 1.8 and 2.0 ng x ml(-1) under 0.8% of the end-tidal sevoflurane concentration. We recorded spontaneous respiratory rate (RR), tidal volume (Vt), and minute volume (MV). After sevoflurane inhalation was finished, the end-tidal sevoflurane concentration at the time at which they responded to command was recorded. Postoperative pain was assessed right after extubation. RESULTS: Although RR decreased in a effect-site concentration of fentanyl dependent manner, V(T) increased gradually, resulting in relatively constant range between 0.5-2.0 ng x ml(-1) of effect-site concentration of fentanyl. Postoperative pain was adequately controlled in the range between 1.2-2.0 ng x ml(-1) of effect-site concentrations of fentanyl. CONCLUSIONS: According to our data, 1.2-2.0 ng x ml(-1) of effect-site concentration of fentanyl could provide adequate postoperative analgesia without respiratory depression in otologic, orthopedic, breast surgery and gynecological laparoscopic procedures.

Measurement of anterior loop length for the mandibular canal and diameter of the mandibular incisive canal to avoid nerve damage when installing endosseous implants in the interforaminal region: a second attempt introducing cone beam computed tomography.

PURPOSE: To measure and compare the anterior loop length (ALL) for the mandibular canal and the mandibular incisive canal diameter (ICD) at its origin in cadavers using anatomy and cone beam computed tomography (CBCT) to safely install endosseous implants in the most distal area of the interforaminal region. MATERIALS AND METHODS: The ALL and ICD were measured using CBCT in 4 cadavers, and using anatomy in 71 cadavers. RESULTS: The ranges and mean +/- SD for the anatomic measurements were: ALL, 0.0 to 9.0 mm and 1.9 +/- 1.7 mm; ICD, 1.0 to 6.6 mm and 2.8 +/- 1.0 mm. The average discrepancies between CBCT and anatomic measurements were 0.06 mm or less for both the ALL and the ICD, which were less than the resolution of CBCT. CONCLUSIONS: Because large variations in measurements were observed, both for ALL and ICD, no fixed distance mesially from the mental foramen should be considered safe. The ALL and the ICD can be estimated from the CBCT measurement. The preoperative CBCT measurement yields important information for each case.

[Anesthetic management for on-pump coronary arterial bypass graft in a patient with cardiac resynchronization therapy].

We experienced anesthetic management for on-pump beating coronary arterial bypass graft in a 73-year-old male patient with cardiac resynchronization therapy (CRT), a non-pharmacological therapy in chronic heart failure. Anesthesia was induced and maintained with sevoflurane and fentanyl under intraaortic balloon pump support. When patient's heartbeat exceeded a pacemaker rate, blood pressure decreased to below 60 mmHg. We tried to perform CRT by adjusting its program above his heart rate, and then blood pressure returned to normal levels. After coronary arterial bypass had been established, it was difficult to wean the patient from cardiopulmonary bypass (CPB) because his own heart rate was over 100 beats min(-1). For the purpose of controlling the heart rate, we administered landiolol intravenously. After injecting a total of 2.5 mg of landiolol, his heart rate was reduced and subsequently CRT started to work, which induced a stable hemodynamic condition enough to wean from CPB. According to our clinical experience, it is important to perform a rapid treatment against tachycardia in a patient with CRT Thus, landiolol is useful for such a rapid treatment against tachycardia with maintaining the hemodynamics.

Fabrication of a maxillofacial prosthesis using a computer-aided design and manufacturing system.

PURPOSE: Maxillofacial prostheses are usually fabricated on the basis of impressions made with dental-impression material. The extent to which the prosthesis reproduces normal facial morphology depends on the clinical judgment of the individual fabricating the prosthesis. This paper describes a computer-aided design and manufacturing (CAD/CAM) system for the fabrication of maxillofacial prostheses. This system will provide a more consistently accurate reproduction of facial morphology. MATERIALS AND METHODS: Facial measurements were taken using a non-contact three-dimensional laser morphological measurement system. The measurements were sent to a computer numerical controlled (CNC) milling machine to generate a cast of the patient's face for the fabrication of prosthesis. RESULTS: Facial contours were measured using a laser. This method minimizes patient discomfort and avoids soft tissue distortion by impression material. Moreover, the digital data obtained is easy to store and transmit, and mirror-images can be readily generated by computer processing. CONCLUSION: This method offers an objective, quantified approach for fabricating maxillofacial prostheses.

[Anesthetic management using HemoSonic 100 in a patient with chronic renal failure and dilated cardiomyopathy].

Anesthetic management for nephrectomy using HemoSonic 100, was performed in a patient with chronic renal failure and dilated cardiomyopathy (DCM). Anesthesia was induced and maintained with infusion of propofol and ketamine, and intermittent administration of fentanyl. During the surgery left ventricular ejection time (LVETc) decreased due to active bleeding from the renal artery. LVETc provided useful information for adequate preload and rate of transfusion in this case. Anesthesia and operation were finished successfully with relatively stable circulatory condition. We conclude that HemoSonic 100 is a useful monitor in anesthetic management of a patient with DCM, especially for the assessment of adequate preload.