Chinzei M

Thoracic epidural catheter insertion using the caudal approach assisted with an electrical nerve stimulator in young children

Objectives We evaluated whether thoracic epidural catheter placement using the caudal approach and assisted with an electrical stimulator could be performed in young children. Methods Ten young children (1-4 years) who underwent abdominal surgeries were studied. Under general anesthesia without muscle relaxants, caudal catheter placement was performed using an 18-gauge Crawford-type needle and a 20-gauge radiopaque epidural catheter with a stainless-steel stylet. A metal adapter and a 3-way stopcock were attached to the catheter to connect to an electrical stimulator and to inject physiological saline. Electrical stimulation was performed intermittently while advancing the catheter until it reached the target length. The catheter position was confirmed on postoperative roentgenogram. Results The mean age of the subjects was 32.2 ± 10.1 months (13-48 months), and the height was 85.3 ± 6.1 cm (72-93 cm). In 9 of 10 patients, an epidural catheter could be placed at the first insertion. In 1 patient, the catheter could be placed successfully at the second insertion. The electrical current required for muscle contraction at the target length was 5.8 ± 1.5 mA. Conclusion Electrical stimulation reliably indicated the location of the catheter tip. This technique for thoracic epidural catheter insertion was easy to perform and could be used in young children.

Pulmonary capillary pressure measured with a pulmonary arterial double port catheter in surgical patients.

We developed a pulmonary artery (PA) double port catheter technique for reliable clinical measurements of pulmonary capillary pressure (Ppc). In seven elective surgical patients, the PA double port catheter with the second PA port 1 cm proximal to the balloon was inserted. The two PA ports, connected to identical pressure measuring systems, provided the pulmonary arterial pressures (Ppa) distal and proximal to the balloon. After general anesthesia was stabilized, the two Ppas were measured simultaneously during a PA occlusion maneuver during 10 s of apnea. The instant of occlusion was determined precisely as the time when the two Ppa traces sharply diverged. A single exponential equation was fitted to the segment of distal Ppa tracing starting 0.3 s after the instant of occlusion. Ppc was determined as the value of the exponential fit extrapolated to time 0. In six of seven patients, PA occlusion occurred consistently in the early systolic phase regardless of the timing of balloon inflation. Mean Ppa, Ppc, and pulmonary arterial wedge pressure were 16.6, 11.8, and 7.6 torr. The ratio of venous to total resistance ranged from 0.37 to 0.54 (mean:0.46). We conclude that this technique is clinically feasible and valuable in precise definition of the instant of PA occlusion. By defining PA occlusion consistently, this technique can provide reliable Ppc estimation in the clinical settings.

Oral nutritional support can shorten the duration of parenteral hydration in end-of-life cancer patients: a randomized controlled trial.

Tube feeding or hydration is often considered for end-of-life cancer patients despite the negative effects on quality of life. The efficacy of oral nutritional support in this setting is unknown. We conducted a randomized trial to compare the efficacies of an amino acid jelly, Inner Power® (IP), and a liquid enteral product, Ensure Liquid® (EL), in terminally ill cancer patients. We randomly assigned patients to 3 arms: EL, IP, and EL+IP. The primary endpoint was drip infusion in vein (DIV)-free survival, which was defined as the duration from nutritional support initiation to administration of parenteral hydration. Twenty-seven patients were enrolled in the study, of whom 21 were included in the intention-to-treat analysis. The median age of the subjects was 69 yr. There were significant differences between the arms with regard to the median DIV-free survival (0.5, 6.0, and 4.5 days in the EL, IP, and EL + IP arms, respectively; P = 0.05). The median overall survival was 7, 9, and 8 days in the EL, IP, and EL + IP arms, respectively. IP may shorten the duration of parenteral hydration in terminally ill cancer patients and does not affect their survival.

Preliminary application of processed electroencephalogram monitoring to differentiate senile dementia from depression

Background:  It is difficult, but important, to distinguish between dementia and depression in old age because senile depression has atypical symptoms, including cognitive impairment and memory disorder. Now brain computed tomography, magnetic resonance imaging, single photon emission computed tomography, and positron emission tomography can be used to differentiate between these two conditions. However, these methods are expensive and not always available. In the present case series, we assessed the potential of monitoring the bispectral index to distinguish between dementia and depression.

Effects of isoflurane and fentanyl on ischemic myocardium in dogs: Assessment by end-systolic measurements

The effect of anesthetics on ischemic myocardium to which blood was supplied by a stenotic coronary artery was investigated in dogs. The ischemia was assessed by regional wall motion (ultrasonic dimension technique) using fractional shortening (FS) [(EDL - ESL)/EDL x 100] and end-systolic pressure-segment length relationships (ESPLR). The latter is considered to be a more load-independent measure of regional myocardial function. Isoflurane and fentanyl were chosen as anesthetics of current interest. On reducing the left circumflex coronary artery (LCX) flow to approximately 50% of its resting value, a decrease in FS and a rightward shift in ESPLR were observed in myocardium perfused by the LCX. Simultaneously, increases in FS were observed in the nonischemic area perfused by the left anterior descending coronary artery (LAD), which was most likely due to the intraventricular unloading effect. No significant changes of ESPLR were observed in the area supplied by LAD. Isoflurane induced a dose-dependent decrease in FS and a rightward shift in ESPLR in the ischemic myocardial segment, whereas fentanyl caused an increase in FS and tended to shift ESPLR leftward in the same area. The results suggest that isoflurane may have deleterious effects on preexisting myocardial ischemia, whereas fentanyl may not when loading conditions are taken into consideration. Fractional shortening and ESPLR seem to provide similar information about regional myocardial function.

Postherpetic neuralgia as a risk factor for classic heatstroke.

On one of the first hot days of summer (ambient temperature 33°C, relative humidity 78%) in late July, the patient took mianserin and slept as normal, without air-conditioning. Early the next morning, she was taken to the emergency room with an axillary temperature of 40.0°C, as a result of exposure to high ambient temperatures throughout the night. The patient vomited on the way to the hospital, and, on arrival, was found to be dehydrated and confused with the following clinical signs: a rectal temperature of 40.0°C; heart rate, 105/ min; blood pressure, 90/50 mmHg; and Glasgow Coma Scale, 13. From these clinical manifestations, her condition was diagnosed as classic heatstroke. She received external cooling and infusions of Ringer’s lactate solution, and, by afternoon, her body temperature had normalized and she was conscious. Results of laboratory tests were normal except for slight hypokalemia and hypoglycemia. On the third day, she was able to walk unattended. On the tenth day, she was discharged from this hospital without sequelae.

CONTROL OF HYPERTENSION DURING ISOFLURANE OR SEVOFLURANE ANESTHESIA WITH CONTINUOUS INFUSION OF NICARDIPINE HYDROCHLORIDE

Abstract In a multicenter study, the efficacy and tolerability of nicardipine hydrochloride (NIC) were examined when the drug was used to control hypertension during isoflurane or sevoflurane anesthesia in patients with or without a preoperative history of hypertension. Retrospectively, the 124 study patients were divided into four groups: patients without (group 1) or with (group 2) a preoperative history of hypertension who received isoflurane anesthesia, and those without (group 3) or with (group 4) a preoperative history of hypertension who received sevoflurane anesthesia. NIC infusion was started when systolic pressure exceeded 160 mm Hg or 30% above the control value determined before the induction of anesthesia. The ability of NIC to control hypertension was analyzed for 30 minutes after starting the infusion. Arterial pressure, heart rate, and urine volume were examined in each group. Mean doses of NIC infused during the 30-minute study period in groups 1, 2, 3, and 4 were 2.23, 2.13, 2.43, and 2.19 μg · kg −1 · min −1 , respectively. There were no significant differences between the four groups in the amount of NIC infused. In the four groups, no significant changes were seen in heart rate, and blood pressure was effectively controlled (group 1: 149.5/86.4 mm Hg and 113.3/63.0 mm Hg before and after the 30-minute study period, respectively; group 2: 156.6/91.2 mm Hg and 118.2/71.0 mm Hg; group 3: 153.4/90.1 mm Hg and 119.0/71.1 mm Hg; and group 4: 160.6/98.7 mm Hg and 124.1/76.8 mm Hg). The final blood pressure measurements were considered within normal ranges for the patients studied. A decrease in blood pressure was slightly delayed in both sevoflurane groups (groups 3 and 4) and in the isoflurane group with a preoperative history of hypertension (group 2). While urine output tended to increase in all groups, a significant increase was found only in group 1 (from 0.019 ± 0.011 mL · kg −1 · min −1 before treatment to 0.087 ± 0.041 mL · kg −1 · min −1 after treatment). In conclusion, NIC was effective and well tolerated in controlling hypertension during isoflurane or sevoflurane anesthesia