[A new bite block for laryngeal mask].

We devised a new bite block made of a used connector of anesthesia machine (ACOMA medical industry CO., LTD.) for laryngeal mask. Fitness for laryngeal mask and strength against patient's biting are the key for its use. Cutting lengthwise the connector (the outside diameter 22 mm, inside diameter 15-19 mm, 55 mm in length) we made a bite block for laryngeal mask. We studied the strength of a new bite block experimentally and recognized its ability to bear the human biting. We conclude a new bite block for laryngeal mask is clinically useful and can be used during anesthesia for its fitness and safety.

Functional differences in yeast protein disulfide isomerases.

PDI1 is the essential gene encoding protein disulfide isomerase in yeast. The Saccharomyces cerevisiae genome, however, contains four other nonessential genes with homology to PDI1: MPD1, MPD2, EUG1, and EPS1. We have investigated the effects of simultaneous deletions of these genes. In several cases, we found that the ability of the PDI1 homologues to restore viability to a pdi1-deleted strain when overexpressed was dependent on the presence of low endogenous levels of one or more of the other homologues. This shows that the homologues are not functionally interchangeable. In fact, Mpd1p was the only homologue capable of carrying out all the essential functions of Pdi1p. Furthermore, the presence of endogenous homologues with a CXXC motif in the thioredoxin-like domain is required for suppression of a pdi1 deletion by EUG1 (which contains two CXXS active site motifs). This underlines the essentiality of protein disulfide isomerase-catalyzed oxidation. Most mutant combinations show defects in carboxypeptidase Y folding as well as in glycan modification. There are, however, no significant effects on ER-associated protein degradation in the various protein disulfide isomerase-deleted strains.

System-Wide Action Team (SWAT)--a new level of collaboration.

A multidisciplinary System-Wide Action Team was coordinated by nursing leadership in response to increasing patient census and acuity. The primary objectives of the team were to develop mechanisms that would expedite patient's admissions and discharges, communicate key messages to all concerned staff, support each other, and communicate announcements about topics or urgent issues that relate to managing the hospital. The team has implemented improvement initiatives around diagnostic testing and scheduling, expediting the admission process, reducing discharge delays, and staffing to hospital census demands.

[The changes of peripheral skin temperature in elderly patients under spinal anesthesia].

The purpose of this study was to evaluate the changes of body temperature in elderly compared with younger patients during spinal anesthesia. Twenty six patients, ASA I-II were divided into two groups, (13; under 30 years of age, 13; above 60 years) who received spinal anesthesia with 0.3% dibucaine at the interspace between L 3 and L 4. All patients were anesthetized below T 8 level. Central temperature was measured at the forehead, and peripheral skin temperature was measured at the finger tip and the toe tip for 25 minutes at every 5 minutes. In both groups, forehead temperature and finger tip skin temperature were unchanged, but toe tip skin temperature increased 5 minutes after spinal anesthesia. The degree of toe tip skin temperature change was significantly lower (P < 0.01) in elderly patients and the speed was also slower. We recognized that the change in peripheral skin temperature during spinal anesthesia is not different between elderly and younger patients, but the speed of temperature change is slower in elderly patients.

Active site mutations in yeast protein disulfide isomerase cause dithiothreitol sensitivity and a reduced rate of protein folding in the endoplasmic reticulum.

Aspects of protein disulfide isomerase (PDI) function have been studied in yeast in vivo. PDI contains two thioredoxin-like domains, a and a', each of which contains an active-site CXXC motif. The relative importance of the two domains was analyzed by rendering each one inactive by mutation to SGAS. Such mutations had no significant effect on growth. The domains however, were not equivalent since the rate of folding of carboxypeptidase Y (CPY) in vivo was reduced by inactivation of the a domain but not the a' domain. To investigate the relevance of PDI redox potential, the G and H positions of each CGHC active site were randomly mutagenized. The resulting mutant PDIs were ranked by their growth phenotype on medium containing increasing concentrations of DTT. The rate of CPY folding in the mutants showed the same ranking as the DTT sensitivity, suggesting that the oxidative power of PDI is an important factor in folding in vivo. Mutants with a PDI that cannot perform oxidation reactions on its own (CGHS) had a strongly reduced growth rate. The growth rates, however, did not correlate with CPY folding, suggesting that the protein(s) required for optimal growth are dependent on PDI for oxidation. pdi1-deleted strains overexpressing the yeast PDI homologue EUG1 are viable. Exchanging the wild-type Eug1p C(L/I)HS active site sequences for C(L/I)HC increased the growth rate significantly, however, further highlighting the importance of the oxidizing function for optimal growth.

[Importance of instructing anesthesiologists in handwashing against bacterial contamination].

The importance of handwashing in preventing the spread of nosocomial infection has been stressed. Using a modified glove juice method, we have already shown the efficacy of washing of anesthesiologists' hands with alcohol based antiseptic solutions against bacterial contamination. The efficacy of handwashing, however, varied because many anesthesiologists washed only the palm and the back. In the present study, we instructed them to wash their hands using rubbing method, from finger tip to the wrist until drying the solutions completely. We compared the efficacy of handwashing, by decrease of bacteria counts after general anesthesia, between the instructed method and the customary way which was done ordinarily in the ward. The instructed method was more effective on the decrease of bacteria counts than the customary way. In the instructed method, the efficacy of handwashing was not different between the antiseptic solutions. In conclusion, doctors not only should practice handwashing with the antiseptic solutions after each contact with the patient, but also wash their hands from the finger tip to the wrist until they become completely dry.

[A patient with Cornelia de Lange syndrome with difficulty in orotracheal intubation].

We experienced a difficult orotracheal intubation in a patient with Cornelia de Lange syndrome. The patient was an eight-year-old girl with Cornelia de Lange syndrome, cleft palate and tetralogy of Fallot who underwent emergency hemicolectomy for strangulation ileus. Orotracheal intubation using a Macintosh laryngoscope was unsuccessful. However, intubation using an endotracheal tube through the laryngeal mask airway with a fiberoptic bronchoscope was successful. The patient's condition was stable during both intubation and operation. In conclusion, we must be careful on endotracheal intubation of patients with congenital anomalies.

[Bacterial contamination of anesthesiologists' hands and the efficacy of handwashing].

The purpose of this study was to examine bacterial contamination, especially by transient skin flora, that were on the hands of trainee and diplomate anesthesiologists during general anesthesia as well as to evaluate the efficacy of washing hands with running water or with three alcohol based antiseptic solutions using a modified glove juice method. The bacterial counts on the anesthesiologists' hands were 3.21 +/- 0.66 [log10 (mean +/- SD)] during induction, 255 +/- 1.15 during maintenance of anesthesia, 2.67 +/- 1.10 during extubation and 3.57 +/- 0.74 at the end of anesthesia. The diplomates' hands were more contaminated than those of the trainees during both intubation and extubation. Washing hands with running water or antiseptic solutions was effective to reduce bacterial contamination, but there was no disinfectant effect of antiseptic solutions against the bacteria that adhered to the hands after drying those solutions. Therefore to prevent nosocomial infection, anesthesiologists should wash their hands with running water or the antiseptic solution after each contact.

[Accuracy of a pulse oximeter during hypoxia].

The accuracy of the pulse oximeter was examined in hypoxic patients. We studied 11 cyanotic congenital heart disease patients during surgery, and compared the arterial oxygen saturation determined by both the simultaneous blood gas analysis (CIBA-CORNING 288 BLOOD GAS SYSTEM, SaO2) and by the pulse oximeter (DATEX SATELITE, with finger probe, SpO2). Ninty sets of data on SpO2 and SaO2 were obtained. The bias (SpO2-SaO2) was 1.7 +/- 6.9 (mean +/- SD) %. In cyanotic congenital heart disease patients, SpO2 values were significantly higher than SaO2. Although the reason is unknown, in constantly hypoxic patients, SpO2 values are possibly over-estimated. In particular, pulse oximetry at low levels of saturation (SaO2 below 80%) was not as accurate as at a higher saturation level (SaO2 over 80%). There was a positive correlation between SpO2 and SaO2 (linear regression analysis yields the equation y = 0.68x + 26.0, r = 0.93). In conclusion, the pulse oximeter is useful to monitor oxygen saturation in constantly hypoxic patients, but the values thus obtained should be compared with the values measured directly when hypoxemia is severe.

[Difficult adult airway and endotracheal intubation].

In 1984, Cormack and Lehane defined laryngoscopic view in four grades. As the view worsens, the difficulty of intubation may increase but it is not clear. In this study, we examined the endotracheal intubation techniques to the grade III or IV airways. Some 48 patients were determined as grade III and IV. In 26 patients the conventional endotracheal intubation technique (conventional technique) was selected. In 20 patients endotracheal intubation was performed over the gum-elastic bougie (bougie technique). In two patients laryngeal mask airway, fiberoptic bronchoscope and handmade flexible guide tube were used as aids to endotracheal intubation (guide technique). Nineteen patients with conventional technique and 6 patients with bougie technique required the external laryngeal pressure. In conclusion, the grade III or IV airways were not always difficult to intubate. But when the conventional technique failed, the gum-elastic bougie or laryngeal mask airway was a fairly useful aid to endotracheal intubation. Moreover our handmade flexible guide tube made the intubation through the laryngeal mask airway safe and reliable.

[Comparison between diltiazem and nicardipine used during anesthesia for coronary revascularization].

The effects of diltiazem (0.1 mg.kg-1 + 3 micrograms.kg-1.min-1) and nicardipine (0.01 mg.kg-1 + 2 micrograms.kg-1.min-1) on circulatory parameters were compared in 30 patients with ischemic heart disease, who underwent coronary revascularization. These drugs were administered intravenously via a Swan-Ganz catheter after induction of fentanyl anesthesia. The group injected with diltiazem showed significant decreases in heart rate, mean arterial pressure, cardiac output, left ventricular stroke work and rate-pressure product. The group injected with nicardipine showed significant decreases in mean arterial pressure, systemic vascular resistance, rate-pressure product and pressure-rate quotient. There were significant differences between the two groups in cardiac output, stroke volume, systemic vascular resistance and left ventricular stroke work. The results suggest that diltiazem protects the ischemic heart by slight cardiac suppression and that nicardipine reduces afterload by marked vascular dilatation during anesthesia for coronary revascularization. Both Ca-channel blockers were demonstrated to be useful.

[Changes in respiration and hemodynamics during open heart surgery without blood transfusion].

The changes in respiration and hemodynamics during open heart surgery were studied in 25 patients undergoing coronary artery bypass grafting without blood transfusion. The respiratory and circulatory parameters were measured at the time of anesthetic induction and after cardiopulmonary bypass (CPB). The values after CPB were compared with those at the time of anesthetic induction. The values of HR, CI, SVI and mPAP increased, and the values of mAP, SVRI and PVRI decreased after CPB. The PaO2, BE and pH decreased but PaCO2, A-aDO2 and QS/QT increased after CPB. Although VO2I and DO2I increased after CPB, OER (VO2I/DO2I) was unchanged. Arterial lactate, pyruvate and cortisol levels increased after weaning from CPB. Hemodynamics during open heart surgery without blood transfusion showed hyperdynamic state after CPB. Hypoxia was not evident in the peripheral tissue. This suggests that the depression of the oxygen delivery with hemodilution is compensated by hyperdynamic circulation. Coronary artery bypass grafting without blood transfusion seems to offer no clinical problems.

Staffing solutions: an in-house agency.

Cost-efficient, flexible labor and scheduling can be met within one's own organization through a professional staffing program. Conceptualization, implementation and evaluation of this in-house agency are detailed. In addition to meeting unit schedules, this program improved staff morale due to better coverage and compensation.

[The circulatory and respiratory effects of methylprednisolone associated with catecholamine administration of a few hours].

We studied the circulatory and respiratory effects of methylprednisolone (MPS) associated with catecholamine administration of a few hours after cardiopulmonary bypass (CPB). Forty patients undergoing coronary artery bypass grafting were randomly divided into two groups. Twenty patients in group 1 [MPS (-) group] did not receive MPS and 20 patients in group 2 [MPS (+) group] received MPS 15 mg.kg-1 i.v. 60 minutes after CPB. The circulatory and respiratory parameters were measured 60 minutes after CPB, 30 minutes after MPS i.v. and 60 minutes after MPS i.v. The values in MPS (-) group were compared with those in MPS (+) group. CI and SVI decreased, and SVRI and PQR increased in MPS (-) group, but these values were unchanged in MPS (+) group. RAP, mPAP, PCWP and PVRI were unchanged in MPS (-) group. PCWP increased and the other values were unchanged in MPS (+) group. The blood gases and pulmonary alveolar function were not different between the two groups. The oxygen delivery decreased in MPS (-) group, but it was unchanged in MPS (+) group. The oxygen consumption was unchanged in the two groups. Blood cortisol increased and epinephrine and norepinephrine decreased in MPS (+) group. Methylprednisolone had an effect to improve the decreased CI and the increased SVRI, and no respiratory problems were observed in patients for coronary artery bypass grafting with catecholamine administration for a few hours after cardiopulmonary bypass.

[Epidural buprenorphine under nitrous oxide-oxygen-enflurane anesthesia in elderly patients].

The effects of epidural buprenorphine (Bn) under nitrous oxide-oxygen-enflurane (E) anesthesia in elderly patients were examined. The subjects were older than 65 years (n = 82) and scheduled for abdominal surgery. They were divided randomly into two groups according to epidural drugs used. The first group received epidural Bn 0.1-0.2 mg (group B, n = 41). The second group received epidural Bn 0.1-0.2mg + 1% lidocaine (group BL, n = 41). The enflurane concentration was 1.13% in group B, and it was significantly higher than 0.78% of group BL (P < 0.01). There was no intra-group difference in the highest systolic blood pressure during operation. The lowest systolic blood pressure during operation was 92.0 +/- 2.1 mmHg in group BL and it was significantly lower than 100.2 +/- 2.9 mmHg of group B (P < 0.05). The percentage of patients who needed vasoconstrictor drugs was 12% in group B, and it was significantly smaller than 42% of group BL (P < 0.01). On the other hand the percentage of patients who needed vasodilator drugs was 39% in group B, and it was significantly larger than 17% of group BL (P < 0.05). There was no intra-group difference in arousing time from anesthesia. Concerning the postoperative respiratory state, there was no intra-group difference in the respiratory rate, tidal volume and PaO2. But the PaCO2 value was 44.7 +/- 0.8 (mean +/- SE) mmHg in group BL, and it was significantly higher than 40.7 +/- 0.7 mmHg of group B (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of sevoflurane and halothane in pediatric anesthesia].

In the present study we compared sevoflurane (group S) and halothane (group F) as used in pediatric endotracheal anesthesia. The subjects consisted of 100 pediatric patients, each 50 in group S and F, most of whom underwent otorhinolaryngological surgery. Anesthesia was induced with nitrous oxide-oxygen-sevoflurane (GOS) (S 3-5%) or nitrous oxide-oxygen-halothane (GOF) (F 1.5-2.5%), and maintained with GOS (S 2-3%) or GOF (F 1.0-1.5%). In comparing the groups with respect to anesthetic induction, group S required 2.1 min for the loss of consciousness, 6.1 min for ocular fixation and 9.7 min for completion of intubation, while in group F the time intervals for the above items were 2.4, 4.9 and 10.2 min, respectively. No significant differences were found between the two groups except in the loss of consciousness and ocular fixation. Comparison of the groups during maintenance of anesthesia revealed no significant differences, although pulse rate and diastolic blood pressure increased in both groups. When the groups were compared for awakening from anesthesia, group S required 10.1 min for awakening and 11.9 min for extubation, while in group F the time was 13.0 min and 15.4 min, respectively. These values were significantly different. The present study demonstrated that sevoflurane anesthesia is rapid in both induction and awakening as compared with halothane anesthesia, and that GOS inhalation anesthesia with single use of sevoflurane can be usefully applied to pediatric endotracheal anesthesia.

[Relation between fingertip temperature pattern and epidural puncture site during epidural anesthesia combined with general anesthesia].

We are employing fingertip temperature monitoring to estimate the spread of epidural anesthesia in patients who received combined epidural and general anesthesia. In this study we examined the relation between fingertip temperature pattern and epidural puncture site. One hundred patients scheduled for elective digestive tract surgery were studied. They were divided into three groups according to the epidural puncture sites as follow; Group 1, T7-9 (n = 26); group 2, T9-12 (n = 48); and group 3, T12-L5 (n = 26). Fingertip temperature was determined by Anritsu thermocouples. These probes were attached to the thumb and the big toe (hand and foot fingertip). The changes of these temperatures were classified to four types. In type 1, the hand fingertip temperatures were elevated after administration of the local anesthetics. In type 2, both hand and foot fingertip temperatures were elevated. In type 3, the foot fingertip temperature was elevated. In type 4, the hand and foot fingertip temperatures were unchanged. In group 1, we found 10 cases of type 1, 13 cases of type 2 and 3 cases of type 3. In group 2; 15, 22, 11 cases respectively. In group 3; 1, 16 cases respectively and 1 case in type 4. In group 1 and 2, the type 1 temperature pattern was observed more than in group 3 (P < 0.01). And in group 3, the type 3 temperature pattern was observed more than in group 1 and 2 (P < 0.01). We found no intergroup difference in type 2 pattern. But there were some exceptions.(ABSTRACT TRUNCATED AT 250 WORDS)

The yeast EUG1 gene encodes an endoplasmic reticulum protein that is functionally related to protein disulfide isomerase.

The product of the EUG1 gene of Saccharomyces cerevisiae is a soluble endoplasmic reticulum protein with homology to both the mammalian protein disulfide isomerase (PDI) and the yeast PDI homolog encoded by the essential PDI1 gene. Deletion or overexpression of EUG1 causes no growth defects under a variety of conditions. EUG1 mRNA and protein levels are dramatically increased in response to the accumulation of native or unglycosylated proteins in the endoplasmic reticulum. Overexpression of the EUG1 gene allows yeast cells to grow in the absence of the PDI1 gene product. Depletion of the PDI1 protein in Saccharomyces cerevisiae causes a soluble vacuolar glycoprotein to accumulate in its endoplasmic reticulum form, and this phenotype is only partially relieved by the overexpression of EUG1. Taken together, our results indicate that PDI1 and EUG1 encode functionally related proteins that are likely to be involved in interacting with nascent polypeptides in the yeast endoplasmic reticulum.

[Changes in forehead and sole tissue temperature during cardiopulmonary bypass for acquired cardiac disease].

The forehead tissue temperature (FT-T) and the sole tissue temperature (ST-T) were measured and recorded by a deep body thermometer (Terumo Corp.) during open heart surgery. The changes in FT-T and ST-T after cardiopulmonary bypass (CPB) showed two characteristic patterns; the convergence pattern and the dissociation pattern. It is said that the dissociation pattern can notes a poor peripheral circulation. The deverging point of the two patterns was studied in 65 patients with acquired cardiac disease. We divided the patients into two groups taking 3.5 degrees C of the FT-T and ST-T difference (DT) after 2 hour weaning from CPB. The number of the patients in convergence group (group I) was 42, and that in the dissociation group (group II) was 23. The two groups were compared with the DT and the time required for the rise in each temperature from CPB rewarming to CPB weaning. There was no intergroup difference in the DT when the FT-T began to rise upon CPB rewarming. However, the DT was 3.8 +/- 2.3 (mean +/- SD) degrees C in group I and 7.1 +/- 1.8 degrees C in group II when the ST-T began to rise, and 4.2 +/- 2.5 degrees C in group I and 6.9 +/- 1.4 degrees C in group II when the FT-T reached its peak; the figures were significantly lower in group I (P < 0.01). The time required for the rise in ST-T was significantly shorter in group I (14.8 +/- 17.1 min) than in group II (25.8 +/- 14.7 min).(ABSTRACT TRUNCATED AT 250 WORDS)