The association between chemotherapy-induced febrile neutropenia and breast cancer subtype in Japanese patients.

Background Chemotherapy-induced febrile neutropenia is a common and potentially lethal side effect; therefore, predicting febrile neutropenia development is important. Objective This study examined the risk factors for febrile neutropenia development according to breast cancer subtype among Japanese patients receiving chemotherapy. Methods This single-center retrospective study evaluated 60 outpatients who received chemotherapy for breast cancer (epirubicin plus cyclophosphamide or docetaxel plus cyclophosphamide). Their characteristics were evaluated to identify factors associated with febrile neutropenia development. Results Thirty-three patients developed febrile neutropenia and 27 patients did not. The risk of developing febrile neutropenia was significantly associated with estrogen receptor negativity (p < 0.05). Logistic regression analysis further confirmed that estrogen receptor negativity was an independent risk factor for febrile neutropenia development (odds ratio: 4.35, 95% confidence interval: 1.05-18.0). Moreover, the highest rate of febrile neutropenia was observed in patients with hormone receptor (estrogen and/or progesterone receptor)-negative/human epidermal growth factor receptor 2-positive breast cancer. Conclusion In addition to the known risk factors for febrile neutropenia, our findings revealed that the risk of developing chemotherapy-induced febrile neutropenia is associated with the hormone receptor-negative/human epidermal growth factor receptor 2-positive subtype in Japanese patients with breast cancer.

[Hyperkalemia after arterial revascularization in a patient undergoing arm replantation].

A 25-year-old man was admitted for arm replantation. His left upper arm was completely amputated by conveyer belt Anesthesia was induced with propofol (80 mg), rocuronium (50 mg), remifentanil (0.15 µg x kg(-1) x min(-1)) and maintained with sevoflurane (1-2%) and remifentanil (0.1-0.3 µg x kg(-1) x min(-1)). The plastic surgeons revascularized subclavian artery quickly but blood pressure decreased to 40-50 mmHg because of massive bleeding and plasma potassium concentration reached 5.8 mEq x l(-1). Noradrenaline (0.3 µg x kg(-1) x min(-1)) and massive albumin on behalf of red blood cells were administered. After we treated hyperkalemia and hypotension, the subclavian vein was successfully revascularized. We should maintain low potassium concentration before revascularization in patients undergoing arm replantation.

Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance.

STUDY OBJECTIVES: To determine the exact mechanism underlying spinal anesthesia-induced hypotension in the elderly patient. DESIGN: Retrospective case-control study. SETTING: Operating room (OR) in a general hospital. MEASUREMENTS: Records from 60 consecutive patients over 80 years of age, who underwent hip fracture repair (intramedullary nail or compression hip screw) during spinal anesthesia were studied. After injection of isobaric 0.5% bupivacaine in the L(3)-L(4) intervertebral space in the lateral decubitus position, patients were turned supine. Acetate Ringer's solution (300 mL) was infused over 30 minutes after subarachnoid puncture. A decrease in systolic arterial pressure to less than 100 mmHg was treated with an intravenous injection of 5 mg ephedrine. The hypotension group (n=18) comprised patients who required ephedrine during the 30 minutes after the puncture, and the nonhypotension group (n=42) consisted of patients who maintained stable arterial pressure with crystalloid infusion only. MEASUREMENTS: Cardiac output (CO) and stroke volume variation (SVV) every 20 seconds using the Vigileo-FloTrac system continuously from arrival in the operating room (OR) to 30 minutes after the subarachnoid puncture were recorded. Serial changes in systemic vascular resistance (SVR), CO, and SVV from baseline after puncture were compared between the two groups. MAIN RESULTS: The decrease in SVR over 20 minutes after the puncture was significantly greater in the hypotension group than the nonhypotension group (P = 0.047). Cardiac output was stable in the two groups. Stroke volume variation in the first 10 minutes after the puncture increased to similar levels in the two groups, then decreased gradually to baseline. No significant differences were noted in circulatory parameters on arrival at the OR. CONCLUSIONS: A decrease in SVR, not CO, is the main mechanism of hypotension seen during spinal anesthesia in elderly patients.

An intraoperative small dose of ketamine prevents remifentanil-induced postanesthetic shivering.

Patients undergoing gynecological laparotomy were randomized to receive either 0.5 mg/kg ketamine at induction of anesthesia followed by an infusion of 0.3 mg/kg/h until the end of surgery (ketamine group, n = 32), or an equivalent volume of normal saline (control group, n = 32). Anesthesia was maintained with IV propofol, a fixed infusion rate of remifentanil (0.25 µg/kg/min), and epidural ropivacaine. Postanesthetic shivering (PAS) was evaluated for 30 minutes after emergence. Intraoperative temperatures were similar between the 2 groups. The incidence of PAS was less frequent in the ketamine group (n = 2, 6%) compared with the control group (n = 12, 38%, P = 0.005). We conclude that, during the early recovery phase, intraoperative ketamine reduces remifentanil-induced PAS.

[Ebstein's anomaly in an adult patient detected by sinus tachycardia by preoperative anesthetic interview].

A 54-year-old man, scheduled for a clavicle fracture repair, appeared asymptomatic with 120 beats x min(-1) tachycardia and ECG abnormalities in preoperative anesthetic interview. He was not suffering from pain derived from clavicle fracture despite tachycardia. He was consulted with a cardiac physician. Downward displacement of tricuspid valve was detected by echocardiography and he was diagnosed Ebstein's anomaly. Right-left shunt did not exist, tricuspid regurgitation was grade I, and LV function was within normal ranges. Hence our anesthetic goal was to avoid arrhythmia, anesthesia was induced and maintained with propofol and remifentanil, and arterial pressure-based cardiac output monitor (FloTrac, Edwards Lifesciences, Irvine, CA, USA) was applied to measure cardiac output. Consequently, heart rate was controlled adequately, and intraoperative anesthetic course was uneventful. The number of adult patients with congenital heart disease has increased because techniques of echocardiography and surgical procedure have been improved. Anesthesiologists should be more aware of congenital heart disease in adults.

[Pitfall in intraoperative electrolyte management for a patient with pseudohyperkalemia caused by thrombocytosis].

An 81-year-old woman was scheduled for gastrectomy due to advanced gastric cancer. Preoperative serum potassium concentration was 6.5 mEq x l(-1), and the operation was postponed. Renal function was normal and hematopathy was denied after bone marrow biopsy. But thrombocyte was 130.5 x 10(4) x mm(-3). Plasma potassium concentration was within normal ranges, and she was diagnosed as pseudohyperkalemia caused by thrombocytosis. Difference between serum and plasma potassium concentrations was more than 1 mEq x l(-1) throughout the surgery. We should take a blood plasma sample in patients with hyperkalemia combined with thrombosis, when renal function was within normal ranges and hemolysis was denied.

Bispectral index during epidural puncture predicts anterograde amnesia in patients given midazolam premedication.

PURPOSE: We hypothesized anterograde amnesia could be predicted by the bispectral index (BIS) during epidural puncture in patients premedicated with intramuscular midazolam. METHODS: We investigated 64 consecutive patients undergoing gynecological laparotomy under general anesthesia combined with epidural anesthesia. Midazolam (5 mg) was administered intramuscularly at 15 min before arrival at the operating room. The anesthesiologist informed the patient of the operating room number after evaluating her using the Observer's Assessment of Alertness and Sedation (OAA/S) scale. A BIS probe was then attached to the patient's forehead while she was in the lateral position for epidural puncture. Another anesthesiologist interviewed the patient on the day after surgery and asked her the operating room number and whether there was recall of pain. Group A comprised patients with no recall of the room number and no recall of pain during epidural puncture and group R comprised patients who remembered both the room number and the pain. Patients recalling only the room number or the pain were excluded. RESULTS: Forty patients were classified as group A and 20 as group R. Four patients remembered only the room number and they were excluded. There were significant differences in body weight, OAA/S scale on arrival at the operating room, and average BIS, and electromyogram (EMG) values during epidural puncture between the two groups. These four parameters were entered into a multiple logistic regression model for multivariate analysis. The analysis identified the BIS value as the only independent predictor of complete amnesia during epidural puncture. CONCLUSION: BIS assessment during epidural puncture is informative for the anesthesiologist to predict amnesia following midazolam premedication.

[Hypertension with tachycardia caused by propofol during induction of general anesthesia].

A 75-year-old man underwent elective posterior lumbar interbody fusion due to canal stenosis. Anesthesia was induced with fentanyl 100 microg, propofol 65 mg (0.95 mg x kg(-1)) and vecronium 7 mg. Bag and mask ventilation was easy and end-tidal sevoflurane reached 3% but arterial blood pressure (ABP) and heart rate (HR) increased to 180-200/90-110 mmHg and 90-110 beats x min(-1) respectively. Additional fentanyl 100 microg and propofol 70 mg were not effective. N2O was started and fentanyl 50 microg and landiolol 5 mg were administerd. Twenty-five minutes after initiation of anesthesia, ABP and HR decreased to 123/76 mmHg and 83 beats x min(-1), respectively. When right ureteral dilatation was undertaken due to obstruction on POD 7, thiamylal 300 mg for anesthetic induction did not increase ABP and HR. Hypertension with tachycardia during induction of general anesthesia can be usually caused by pain, hypoventilation, intracranial hemorrhage and myocardial ischemia etc but all of them were denied in this clinical course. Previous reports had shown that a small amount of propofol itself induced vasoconstriction and we concluded that a low dose of propofol to avoid hypotension during induction could cause hypertension with tachycardia.

[Efficacy and safety of AirWay Scope in using a bronchofiberscope in patients with difficult airway].

Case 1: A 41-year-old woman was scheduled for pinning of fractured finger and repair of a ligamentum. Preoperative problems did not exist except mandibular hypoplasia. General anesthesia was induced and Cormack classification was grade III in laryngeal view by laryngoscope and we tried a new videolaryngoscope PENTAX-AirWay Scope (AWS). We did not catch the epiglottis directly by Intlock and the target mark was not located at the middle of the vocal cord. Bronchofiberscope was guided to the vocal cord through a tracheal tube attached to AWS by another anesthesiologist and the patient was successfully intubated. Case 2: A 46-year-old man was scheduled for anterior screw-plate fixation due to C3/4 herniated disc. AWS using bronchofiberscope procedure was tried to keep the neutral position of the neck. The patient was successfully intubated. We did not view the bronchofiberscope and used it just as a flexible bougie. Case 3: A 56-year-old man was scheduled for free radial forearm flap reconstruction of a diabetic necrotic toe. Ten minutes were needed to finish intubation due to difficult airway (Cormack classification grade III) when free latissimus dorsi flap reconstruction was perfomed two month before. Hence, AWS using a bronchofiberscope procedure was tried first and 39 seconds were needed to intubate. We concluded that AWS using bronchofiberscope procedure was useful for patients with difficult airway, though two anesthesiologist, one keeping AWS and the other using a bronchofiberscope, were needed.

[Patients hospitalized the day before operation are satisfied with outpatient preoperative evaluation system].

BACKGROUND: Recently, shortening of hospitalization has increased the number of hospitalization the day before operation in Japan. Appropriate preoperative anesthetic evaluation systems should be developed to maintain the same quality and efficiency of evaluation as for patients hospitalized earlier. Patient satisfaction is an important consideration in this program. METHODS: We adopted an outpatient preoperative evaluation system for patients hospitalized the day before operation, using an original anesthesia application form, from November 2006. Forms containing multiple-choice questions regarding medical history and medications were completed by patients' doctors and submitted to us before evaluation. We examined the system use each month and conducted a survey using questionnaires on patient satisfaction in 42 patients using the system 8 months after its introduction. RESULTS: The proportion of patients using the system among surgical patients increased from 8.9% to 45.2% in half a year. The application form yielded detailed information efficiently and enabled sufficient preoperative management. In the questionnaire survey, 94.1% of the patients were satisfied with our new system due to early understanding and anxiety reduction, reduction of burden after hospitalization, and appropriate preoperative management. CONCLUSIONS: Our new system enabled improvement in quality and efficiency of perioperative management and increase in patient satisfaction in preoperative evaluation for hospitalization the day before operation.

[Effect of long-term treatment with royal jelly on insulin resistance in Otsuka Long-Evans Tokushima Fatty (OLETF) rats].

Royal jelly (RJ) is known to have abundant nutritional properties and a variety of biological activities. To investigate the effects of RJ on insulin resistance, 10-week-old Otsuka Long-Evans Tokushima Fatty (OLETF) rats, a type 2 diabetic model, were treated for 4 weeks with RJ (10, 30, and 300 mg/kg, p.o.). RJ treatment tended to decrease systolic blood pressure and significantly decreased serum levels of insulin and the Homeostasis Model Assessment ratio, an index of insulin resistance. In isolated and perfused mesenteric vascular beds of OLETF rats, RJ treatment resulted in significant reduction of the sympathetic nerve-mediated vasoconstrictor response to periarterial nerve stimulation (PNS) and potentiation of the calcitonin gene-related peptide (CGRP) nerve-mediated vasodilator response to PNS, compared with that in untreated OLETF rats. However, RJ treatment did not significantly affect norepinephrine-induced vasoconstriction and CGRP-induced vasodilation. These results suggest that RJ could be an effective and functional food to prevent the development of insulin resistance.