Skin blood flow and plasma catecholamine concentrations during removal of a phaeochromocytoma in a child.

A 9-yr-old boy with an adrenal phaeochromocytoma underwent removal of the tumour under general anaesthesia using sevoflurane and nitrous oxide combined with thoracic epidural anaesthesia. Skin blood flow in the first toe, as measured by laser Doppler flowmetry, markedly decreased during manipulation of the tumour and increased after removal of it. Skin blood flow correlated more significantly with plasma catecholamine concentrations than did mean arterial blood pressure. Skin blood flow may be used as a non-invasive measure of plasma catecholamine concentrations during removal of a phaeochromocytoma in paediatric patients.

[Pseudohypoxemia in a patient with chronic myeloid leukemia and splenomegaly].

A 35-year-old man with chronic myeloid leukemia whose peripheral leukocyte count was 18.6 x 10(4).mm-3 underwent splenectomy. Perioperative arterial blood gas analysis showed lower oxygen saturations than those measured with pulse oximetry. The findings suggested pseudohypoxemia because of marked leukocytosis.

Depression of evoked electromyographic (EEMG) responses by propofol in a patient with human T-cell lymphotropic virus type I-associated myelopathy (HAM).

IMPLICATIONS: We report a patient with human T-cell lymphotropic virus type I-associated myelopathy. Although muscle strength in both of the upper extremities was normal in this patient, evoked electromyogram of the adductor pollicis was depressed by propofol at the induction of anesthesia.

Growth of Escherichia coli in propofol, lidocaine, and mixtures of propofol and lidocaine.

BACKGROUND: Microorganisms grow rapidly in propofol. Extrinsic contamination of propofol is thought to be a source of postoperative sepsis and wound infection. We studied growth of a strain of Escherichia coli in thiopental, propofol, lidocaine, and mixtures of propofol and lidocaine. METHODS: The pathogen was exposed to 2.5% thiopental; 1.0% propofol; 1.0%, 2.0% and 4.0% preservative-free lidocaine; and propofol solutions containing 0.25%, 0.5%, 1.0%, 2.0%, or 4.0% lidocaine for 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 h at room temperature, respectively. The inocula from these suspensions were cultured for 48 h at 37 degrees C after the antimicrobial activity of the local anesthetics in the inocula was inactivated by a 1:1000 dilution with distilled water. RESULTS: No organisms grew after exposure to 2.5% thiopental. The exposure of E. coli to propofol increased the colony count to approximately 90 times the control count. The colony counts of E. coli after exposure to 1.0%, 2.0% and 4.0% lidocaine and 0.25%, 0.5%, 1.0%, 2.0% and 4.0% lidocaine in 1.0% propofol were lower than the counts after exposure to 1.0% propofol (P = 0.0048, 0.0027, 0.0003, 0.0503, 0.0188, 0.0080, 0.0044, and 0.0001, respectively). The growth rate of the microorganism was significantly higher in cultures exposed to 1.0% propofol than that in cultures exposed to lidocaine alone or lidocaine-propofol mixtures (P < 0.0001, respectively). CONCLUSION: Lidocaine possesses bacteriostatic activity against E. coli. Addition of lidocaine to propofol confers its bacteriostatic activity to the mixture and may decrease the hazard of infection associated with the extrinsic contamination of propofol.

Systemic immune response after intravesical instillation of bacille Calmette-Guérin (BCG) for superficial bladder cancer.

The mechanism of anti-tumour activity by BCG is not known clearly. However, many studies suggest that immunological response is related to effectiveness of intravesical instillation of BCG in the therapy for superficial bladder carcinoma. Peripheral blood mononuclear cells (PBMC), urine and serum were obtained from patients with superficial carcinoma at various times during the course of BCG instillation. Urine of patients showed increased levels of IL-1beta, IL-2, IL-6, tumour necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma) and macrophage colony-stimulating factor (M-CSF) after BCG instillation. Levels of IL-2 and IFN-gamma in the serum also increased after BCG instillation, but IL-1beta, IL-6, TNF-alpha and M-CSF were not detectable. Maximal levels of IL-2 and IFN-gamma in the urine or serum were shown after the fourth instillation. BCG-induced killer cell activity in PBMC increased significantly after the third BCG instillation. These results suggest that BCG instillation involved not only local immunological efforts but also systemic immune responses. Tumour-free patients produced higher BCG-induced killer cell activity than tumour recurrence patients. BCG-induced killer cell activity may be useful for monitoring the effectiveness of intravesical BCG instillation.

Response to vecuronium in a patient with facioscapulohumeral muscular dystrophy.

Increased sensitivity to vecuronium has been noted in patients with Duchenne muscular dystrophy. We report the response to vecuronium in a patient with facioscapulohumeral muscular dystrophy (FSHD), an autosomal dominant disorder with an incidence of 10-20 cases per million. In this patient, sensitivity to an initial dose of vecuronium (0.02 + 0.08 mg kg-1) was normal, but recovery was faster and the effect of incremental doses of vecuronium (0.02 mg kg-1) was less than expected. Onset time and 25% recovery of T1/T0 after the intubating dose of vecuronium were 240 s and 22 min, respectively. Recovery index (spontaneous recovery of T1/T0 from 25% to 75%) was 9 min.

Bactericidal activity of preservative-free bupivacaine on microorganisms in the human skin flora.

BACKGROUND: The rate at which the bactericidal activity of preservative-free bupivacaine develops at body temperature and at room temperature is not known. We studied the bactericidal activity of preservative-free bupivacaine on two strains of methicillin-resistant Staphylococcus aureus (MRSA), two strains of methicillin-susceptible S. aureus (MSSA), and each of Staphylococcus epidermidis and Escherichia coli. METHODS: The pathogen was exposed to 0.5% bupivacaine for 1, 3, 6, 12, and 24 h at 37 degrees C and room temperature. In addition, each strain of MRSA, MSSA, and S. epidermidis was exposed to distilled water, and 0.125%, 0.25%, 0.5%, and 0.75% bupivacaine at 37 degrees C. The inocula from the suspensions were cultured for 48 h at 37 degrees C. RESULTS: The 1- through 24-h exposures of 4 strains of S. aureus to 0.5% bupivacaine at room temperature reduced the colony count by 21.7%, 34.7%, 51.1%, 65.6%, and 81.1%, respectively, and the exposure at 37 degrees C reduced the count by 34.1%, 50.8%, 66.3%, 94.5%, and 96.0%, respectively. The differences were significant at all exposure times (P < 0.001, respectively). No organisms grew in the strain of E. coli after 24-h exposure and in the strain of S. epidermidis after 12- and 24-h exposures at 37 degrees C. The percent change from controls in the strains of E. coli and S. epidermidis was significantly higher than that in the strains of S. aureus at all exposure times at room temperature and 37 degrees C (P < 0.0001, respectively). Higher concentrations of bupivacaine were associated with lower colony count. CONCLUSION: Our results show that preservative-free bupivacaine possesses a temperature- and concentration-dependent bactericidal activity, and S. aureus is more resistant to the bactericidal activity of bupivacaine than are S. epidermidis and E. coli.

Rupture of the left main-stem bronchus by the tracheal portion of a double-lumen endobronchial tube.

We report a rupture of the left main-stem bronchus following the insertion of a left-sided double-lumen endobronchial tube in a 76-yr-old woman with a short trachea. A fiberoptic bronchoscope was not used during the initial insertion of the tube and the depth of insertion resulted in approximately 5 cm in excess of the optimal level for this patient. The rupture had been caused by the tracheal portion of the double-lumen tube. This damage may have been avoided if a fiberoptic bronchoscope was used routinely as an introducer and for positioning of the endobronchial tube under direct vision.

Bactericidal activity of 0.5% bupivacaine with preservatives on microorganisms in the human skin flora.

BACKGROUND AND OBJECTIVES: The bactericidal activity of 0.5% bupivacaine with preservatives at body temperature and at room temperature is not known. We studied the bactericidal activity of 0.5% bupivacaine with 0.08% methyl para-oxybenzoate and 0.02% propyl para-aminobenzoate as preservatives and of the preservatives alone at 37 degrees C and at room temperature on two strains of methicillin-resistant Staphylococcus aureus, two strains of methicillin-susceptible S. aureus, and one strain each of Staphylococcus epidermidis and Escherichia coli. METHODS: The pathogen was exposed to 0.5% bupivacaine with preservatives or to the preservatives alone for 1, 3, 6, 12, and 24 hours at 37 degrees C and at room temperature. The inocula from these suspensions were cultured for 48 hours at 37 degrees C after the antimicrobial activity of bupivacaine was inactivated by 1:1,000 dilution with physiological saline. RESULTS: The 1- through 12-hour exposures of four strains of S. aureus to 0.5% bupivacaine with preservatives at room temperature reduced the mean colony count by 24.2%, 49.2%, 71.3%, and 89.6%, respectively, and the exposure at 37 degrees C reduced the count by 74.1%, 95.2%, 99.9%, and 99.8%, respectively. The differences for 1- through 12-hour exposures were significant (P < .001). The percentage kill in the strains of E. coli and S. epidermidis was significantly higher than that in the strains of S. aureus at all exposure times at room temperature (E. coli, P < .001; S. epidermidis, P < .0001) and at 1- and 3-hour exposures at 37 degrees C (E. coli, P < .001; S. epidermidis, P < .0001). The bactericidal activity of the preservatives was markedly lower that that of 0.5% bupivacaine with preservatives (P < .0001). CONCLUSIONS: The bactericidal activity of 0.5% bupivacaine with preservatives is stronger at body temperature than at room temperature; the bactericidal activity may be due, to a large extent, to bupivacaine rather than to the preservatives; and S. aureus is more resistant to the bactericidal activity of bupivacaine than are S. epidermidis and E. coli.

A Case of Dermatofibrosarcoma Protuberans in the Skin over the Breast.

Dermatofibrosarcoma protuberans (DFSP) is a slow-growing but locally aggressive, fibrous tumor that has a high rate of local recurrence after surgical resection. This tumor occurs most commonly in the trunk and proximal extremities. In this report we present a case of dermatofibrosarcoma protuberans in the skin over the breast which was re-excised after pathological diagnosis, considering cosmetic aspects. Only three other cases of dermatofibrosarcoma protuberans of the anterior chest wall have been encountered in our hospital, and all of these cases were male. The presence of this tumor in the skin over the breast appears to be rare in females. Careful complete resection is recommended for this type of tumor.

Human skin flora as a potential source of epidural abscess.

BACKGROUND: The mechanism of epidural infection associated with epidural block is not clearly understood. Resident organisms in skin specimens were studied after skin was prepared with disinfectants. METHODS: Sixty-nine paired skin specimens were excised at incisional sites after skin disinfection with 10% povidone-iodine (10% PVP-I) or 0.5% chlorhexidine in 80% ethanol (0.5% CHE) from 60 patients having back surgery. One of the specimen pairs was placed in 10 ml brain-heart infusion broth and incubated in air at 37 degrees C for 96 h. The other specimen was sectioned at 3 microns and prepared with Gram's stain for examination with the microscope. RESULTS: Thirteen gram-positive staphylococcal species (Staphylococcus epidermidis, 69.2%; S. hyicus, 15.4%; and S. capitis, 15.4%) were isolated from cultures. The isolates were found in a significantly greater proportion of the skin specimens disinfected with 10% PVP-I than in those disinfected with 0.5% CHE (11 of 34 cultures [32.4%] vs. 2 of 35 cultures [5.7%]; P < 0.01). Many gram-positive cocci were observed with the microscope in 4 (11.8%) and 5 (14.3%) of 34 and 35 skin specimens disinfected with 10% PVP-I and 0.5% CHE, respectively. The cocci formed a dense colony in each follicle and in the stratum corneum. No organism was present in any of 17,584 sweat glands examined. CONCLUSIONS: In a large proportion of patients, isolation of viable organisms from excised skin specimens after disinfection with 10% PVP-I suggests that contamination of the epidural space by the skin flora may be a potential mechanism of epidural infection associated with epidural block.

Retrospective analysis of the treatment of patients with small cell lung cancer showing poor performance status.

To assess the feasibility of treatments for patients with small cell lung cancer (SCLC) showing a poor performance status (PS, Eastern Cooperative Oncology Group; ECOG 3 or 4), we retrospectively reviewed the outcome for 13 SCLC patients showing poor PS treated at the National Cancer Center Hospital between January 1984 and May 1994. The main factors which contributed to poor prognosis were superior vena cava (SVC) syndrome, massive pleural effusion, tracheal stenosis due to lymph node swelling, pericardial effusion and pulmonary fibrosis (causing dyspnea in combination), brain metastasis resulting in neurological disturbance, cachexia, Eaton-Lambert syndrome causing muscle weakness, retroperitoneal lymph node metastasis causing abdominal pain, peritoneal effusion due to abdominal lymph node swelling, vertebral metastasis causing paraplegia, and dermatomyositis/polymyositis (DM/PM) causing muscle weakness. All of the patients received chemotherapy with or without radiotherapy. The PS of 8 patients improved with treatment, but no improvement was seen in 5. We analyzed these 13 patients and considered the treatments for those with poor PS. Chemo-radiotherapy was tolerable in SCLC patients showing PS 3, and improved their PS if severe conditions or combined disease did not arise concurrently. It was further suggested that PS 4 patients with severe conditions or combined disease should not be given the treatments.

Bactericidal activity of clinically used local anesthetics on Staphylococcus aureus.

BACKGROUND AND OBJECTIVES: The rate of onset of antimicrobial activity of local anesthetics is unknown. Similarly, whether the activity is bactericidal or bacteriostatic is also unknown. The antimicrobial activity of local anesthetics with preservatives has not been studied. This study investigated the rate and potency of the antimicrobial activity of 0.125%, 0.25%, and 0.5% bupivacaine, 2.0% mepivacaine and 2.0% lidocaine with preservatives, and 2.0% lidocaine without preservatives on two strains of methicillin-resistant Staphylococcus aureus. METHODS: The pathogen was exposed to each local anesthetic for 1, 3, 6, 12, and 24 hours at room temperature. The inocula from these suspensions were diluted to 1:1,000 with physiological saline to inactivate the antimicrobial activity of the local anesthetics and then were cultured for 24 hours at 37 degrees C on agar plates. RESULTS: Lower colony counts were observed with a 3-hour or longer exposure to 0.5% bupivacaine in both strains of S. aureus (P < .05). The 3-hour exposure reduced the count by approximately 60%, the 6-hour exposure by 70%, and the 24-hour exposure by more than 99%. The bactericidal activity was lowest with 0.125% bupivacaine and 2.0% mepivacaine. CONCLUSIONS: Antimicrobial activity was observed shortly after exposure of S. aureus to local anesthetics and appeared to be bactericidal rather than bacteriostatic. However, the observed bactericidal activity, although it developed rapidly, may be insufficient to account for the low incidence of epidural infection related to epidural cannulation.