Hiromichi Ichinose

Analgesic effect of epidural neostigmine after abdominal hysterectomy.

STUDY OBJECTIVEnTo evaluate the effects of epidurally administered neostigmine on pain after abdominal hysterectomy.nnnDESIGNnProspective, randomized, double-blind study.nnnSETTINGnTeaching hospital.nnnPATIENTSn45 ASA physical status I adult patients scheduled for abdominal hysterectomy.nnnINTERVENTIONSnAll patients received identical general and epidural anesthesia. At the end of the surgery, they received epidural bupivacaine (10 mg) with either saline (control group, n = 15), 5 micro g/kg (5-micro g group, n = 15), or 10 micro g/kg neostigmine (10-micro g group, n = 15). Postoperatively, 50 mg diclofenac suppository was given for pain relief on patient demand.nnnMEASUREMENTS AND MAIN RESULTSnThe time to first diclofenac administration and the number of times diclofenac was required during the first 24 postoperative hours were recorded. Pain was assessed using a 10-cm visual analog pain scale (VAS) at rest at the first diclofenac request, and at 15 and 24 hours after surgery. The time to first diclofenac administration was significantly longer (p < 0.05) in the 10-micro g group (223 +/- 15 min) than in the control (78 +/- 17 min) or 5-micro g groups (88 +/- 18 min). However, epidural neostigmine at both doses did not reduce the number of postoperative diclofenac administrations. There were no differences in VAS among the three groups.nnnCONCLUSIONSnEpidural neostigmine of 10 micro g/kg in bupivacaine provides a longer duration of analgesia than does bupivacaine alone or with 5 micro g/kg of neostigmine after abdominal hysterectomy.

Perioperative intravenous flurbiprofen reduces postoperative pain after abdominal hysterectomy

Purpose: To assess whether perioperative intravenous administration of flurbiprofen, a non-steroidal anti-inflammatory drug, reduced postoperative pain after abdominal hysterectomy.Methods: Forty-five patients undergoing abdominal hysterectomy were randomly assigned to one of three groups of equal size. A control group (CONT) received a placebo 30 min before and at the end of surgery. The other two groups, PRE and POST, received 1 mg·kg−1 flurbiprofeniv 30 min before and at the end of surgery, respectively. All patients received identical general and epidural anesthesia. Postoperatively, 50 mg diclofenacpr was given for pain relief on patient demand. One of the authors assessed pain using a 10 cm visual analog scale at rest and during coughing at the first request for diclofenac, and at 15, 24, 48, and 72 hr after surgery. The number of times diclofenac was required during the first 24 hr after surgery was also recorded.Results: The number of diclofenac requests in the PRE (1.8±0.4) and POST groups (2.0±0.4) were less than in the CONT group (3.0±0.4). The PRE group showed lower visual analog scale at rest at 15 and 24 hr and on coughing at 24, 48, and 72 hr after surgery than the CONT and POST groups.Conclusion: intravenous 1 mg·kg− flurbiprofen administered during anesthesia reduces postoperative rescue analgesic requirement after abdominal hysterectomy. Moreover, flurbiprofen is more effective when given before than after surgery.RésuméObjectif: Vérifier si l’administration intraveineuse périopératoire de flurbiprofène, un anti-inflammatoire non stéroïdien, réduit la douleur postopératoire d’une hystérectomie abdominale.Méthode: Quarante-cinq patientes devant subir une hystérectomie abdominale ont été réparties au hasard en trois groupes égaux. Un groupe témoin (TEM) a reçu un placebo, 30 min avant et à la fin de l’opération. Les deux autres groupes, PRE et POST, ont reçu 1 mg·kg−1 de flurbiprofèneiv 30 min avant et à la fin de l’intervention, respectivement. Toutes les patientes ont reçu une anesthésie générale et épidurale identique. Après l’intervention, 50 mg de diclofénacpr ont été administrés sur demande comme analgésie. Un des auteurs a évalué la douleur en utilisant une échelle visuelle analogique de 10 cm, au repos et pendant la toux à la première demande de diclofénac et, puis à 15, 24, 48 et 72 h après l’opération. On a aussi noté le nombre de demandes de diclofénac pendant les 24 premières heures postopératoires.Résultats: Les demandes de diclofénac dans les groupes PRE (1,8±0,4) et POST (2,0±0,4) ont été moins nombreuses que dans le groupe TEM (3,0±0,4). Le groupe PRE a donné des scores plus bas à l’EVA au repos à 15 et 24 h et lors de la toux à 24, 48, et 72 h après l’intervention, en comparaison avec les groupes TEM et POST.Conclusion: L’administration intraveineuse de 1 mg·kg−1 de flurbiprofène pendant l’anesthésie réduit les besoins d’analgésie postopératoire à la suite d’une hystérectomie abdominale. De plus, le flurbiprofène est plus efficace lorsqu’on l’adminsitre avant qu’après l’intervention chirurgicale.

The effect of fentanyl on hemodynamic and bispectral index changes during anesthesia induction with propofol

STUDY OBJECTnTo investigate the changes in hemodynamics and hypnotic levels during propofol infusion and tracheal intubation with and without fentanyl.nnnDESIGNnRandomized, double-blinded study.nnnSETTINGnTeaching hospital.nnnPATIENTSn40 ASA physical status I adult patients scheduled for elective surgery.nnnINTERVENTIONSnPatients were anesthetized with either propofol (Group P; n = 20) or 2 microg/kg of fentanyl IV followed by propofol (Group PF; n = 20). Propofol was infused at 20 mg/kg/hr throughout the study, and tracheal intubation was performed 10 minutes after the start of propofol infusion.nnnMEASUREMENT AND MAIN RESULTSnBispectral index monitoring (BIS) progressively decreased to about 50 in both groups during infusion of propofol, but no difference was found between the two groups. After tracheal intubation, BIS significantly increased but remained below 60 in both groups. Hypertensive responses to intubation were fewer in Group PF than Group P.nnnCONCLUSIONSnPropofol administration 20 mg/kg/hr for 10 minutes is suitable in suppressing arousal reactions to tracheal intubation, but the addition of fentanyl is required to blunt the hemodynamic responses.

The bispectral index response to tracheal intubation is similar in normotensive and hypertensive patients

PurposeTo compare the hemodynamic and bispectral index (BIS) responses to tracheal intubation in normotensive and hypertensive patients.MethodThree minutes after induction of anesthesia with thiamylal and fentanyl, tracheal intubation was performed in 24 normotensive and 22 hypertensive patients. Heart rate (HR), mean arterial pressure (MAP), and BIS were measured every minute.ResultsTracheal intubation increased HR, MAR and BIS in both normotensive and hypertensive patients. The increase in MAP was significantly greater in hypertensive patients than in normotensive patients, but there were no differences in HR or BIS in the two groups of patients.ConclusionPatients with and without hypertension exhibit the same arousal response (as measured by BIS) to tracheal intubation despite the enhanced vasopressor response in hypertensive patients.RésuméObjectifComparer les réponses hémodynamiques et de l’index bispectral (BIS) à l’intubation endotrachéale chez des patients normotendus et hypertendus.MéthodeTrois minutes après l’induction de l’anesthésie avec du thiamylal et du fentanyl, l’intubation endotrachéale a été réalisée chez 24 patients normotendus et 22 hypertendus. La fréquence cardiaque (FC), la tension artérielle moyenne (JAM) et le BIS ont été mesurés à toutes les minutes.RésultatsL’intubation endotrachéale a fait augmenter la FC, la TAM et le BIS chez les patients des deux groupes. Laccroissement de la TAM a été signifcativement plus élevé chez les hypertendus, mais il n’y a pas eu de différence intergroupe pour la FC ou le BIS.ConclusionLes patients hypertendus ou non réagissent par la même réaction d’éveil (mesurée par le BIS) à l’intubation endotrachéale malgré l’augmentation de la réponse vasopressive chez les hypertendus.

Values of the bispectral index do not parallel the hemodynamic response to the rapid increase in isoflurane concentration.

PurposeTo investigate the changes in hemodynamic variables and bispectral index (BIS) in response to a rapid increase in isoflurane or sevoflurane concentration.MethodThirty adult patients were anesthetized with either isoflurane (isoflurane group) or sevoflurane (sevoflurane group). Two minutes after induction of anesthesia with thiamylal, the inspired concentrations of isoflurane and sevoflurane were rapidly increased from 0.5 minimum alveolar anaesthetic concentration (MAC) to 3 MAC and maintained for five minutes. Heart rate (HR), mean arterial pressure (MAP), and BIS were measured every minute.ResultsAn increase in the anesthetic concentration caused increases in HR and MAP in the isoflurane group and a decrease in MAP in the sevoflurane group. Consequently HR and MAP in the isoflurane group were significantly higher than those in the sevoflurane group. After inhalation of high concentrations, BIS significantly and progressively decreased in both groups.ConclusionBIS values decrease after a step increase in volatile agent concentration, whether or not a hyperdynamic action occurs.ObjectifExaminer les changements des variables hémodynamiques et de l’index bispectral (BIS) en réponse à une augmentation rapide de la concentration d’isoflurane ou de sévoflurane.MéthodeTrente patients adultes ont été anesthésiés avec de l’isoflurane ou du sévoflurane et ainsi répartis en deux groupes. Deux minutes après l’induction de l’anesthésie avec du thiamylal, les concentrations d’isoflurane et de sévoflurane inspirées ont été rapidement augmentées d’une concentration alvéolaire minimale de 0,5 (CAM) à 3 MAC et maintenue pendant cinq minutes. La fréquence cardiaque (FC), la tension artérielle moyenne (TAM) et le BIS ont été mesurés à chaque minute.RésultatsUne augmentation de la concentration de l’anesthésique a entraîné une augmentation de la FC et de la TAM dans le groupe isoflurane et une baisse de la TAM dans le groupe sévoflurane. Par conséquent, la FC et la TAM ont été significativement plus élevées dans le groupe isoflurane que dans le groupe sévoflurane. Après l’inhalation de fortes concentrations, le BIS a diminué de façon progressive et significative dans les deux groupesConclusionLes valeurs du BIS diminuent à la suite d’une augmentation rapide de la concentration de l’anesthésique volatil, qu’une réaction hyperdynamique survienne ou non.

Monitoring of skeletal muscle oxygenation using near-infrared spectroscopy during abdominal aortic surgery

AbstractPurpose. To examine the utility of near-infrared spectroscopy (NIRS) in assessing lower-leg perfusion, NIRS was performed on the calf muscles of patients who underwent abdominal aortic surgery.nMethods. Thirty patients undergoing elective infrarenal abdominal aortic surgery for abdominal aortic aneurysm (AAA group; n = 16) and aorto-occlusive disease (AOD group; n = 14) were studied. Before induction of anesthesia, NIRS probes were placed over both calf muscles, and muscle oxygen saturation (StO2) was continuously monitored throughout the surgery.nResults. The preoperative StO2 value was significantly lower in the AOD group (57.0 ± 11.2%) than in the AAA group (68.7 ± 7.0%). In both groups, StO2 significantly decreased after aortic cross-clamping; the maximal ischemic value of StO2 in the AAA group (17.8 ± 7.2%) was significantly lower than that in the AOD group (46.7 ± 17.1%). The time taken to reach maximal ischemia was significantly longer in the AAA group (30 ± 12 min) than in the AOD group (19 ± 12 min). After release of the aortic clamp, the decreased StO2 returned to the preoperative level in the AAA group, whereas it increased above the preoperative value in the AOD group.nConclusion. NIRS performed on the calf muscles is a useful method for assessing the changes in lower-leg perfusion during and after abdominal aortic surgery.

Comparison of the clinical performances of Air-Qsp and i-Gel for airway management under general anesthesia with a muscle relaxant.

STUDY OBJECTIVESnRecently, i-Gel intubating laryngeal airway (ILA) has been frequently used because of the ease for airway insertion by residents and young anesthesiologists. However, it sometimes fails to fit or ventilate sufficiently in Japanese patients. Use of Air-Qsp, which is a new non-inflatable cuffed ILA, in a clinical setting has become possible. The purpose of this study was to compare the clinical performance of Air-Qsp with that of i-Gel for airway management in Japanese adult patients.nnnDESIGNnA randomized, single-blinded, prospective study was conducted after approval from the institutional review board.nnnSETTINGnOperating rooms at hospitals.nnnPATIENTSnThirty-seven adult patients aged 20 to 69 years, with ASA physical status I or II, and scheduled for elective surgery under general anesthesia in the supine position.nnnINTERVENTIONSnPatients were randomly assigned to insertion with Air-Qsp (Group A: n=20) or i-Gel (Group I: n=17).nnnMEASUREMENTSnThe number of insertions, duration of insertion, changes in systolic blood pressure and heart rate during insertion, delivered tidal volume for setting volume control ventilation, distribution of the tips of the bronchofiberscopes (BFs) on a clock face, and the number of postoperative complications was evaluated.nnnMAIN RESULTSnTwo patients in Group A and one patient in Group I were excluded because insertion of the device failed. There were no significant differences in measured parameters between the 2 groups. The distribution of the tips of the bronchofiberscopes tended to be around the center of the glottis in Group A, whereas they were more toward the 6-oclock position in Group I.nnnCONCLUSIONSnAir-Qsp is as useful as i-Gel in Japanese patients and the distributions of the tips of BFs through ILAs are different for Air-Qsp and i-Gel.

Effect of Intraoperative Glucose Infusion on Catabolism of Adipose Tissue and Muscle Protein in Patients Anesthetized With Remifentanil in Combination With Sevoflurane During Major Surgery: A Randomized Controlled Multicenter Trial

BACKGROUND:A harmful effect of stress hormone secretion during surgery is lipolysis and proteolysis to maintain normal blood glucose levels. A well-titrated general anesthetic improves blood glucose control by suppressing secretion of these stress hormones. The aim of this study was to explore the effect of intraoperative glucose infusion on lipolysis and proteolysis in patients undergoing a general anesthetic consisting of sevoflurane and remifentanil during long (>6 hours) major surgery. METHODS:In this prospective, single-blinded, randomized, multicenter trial, 80 patients with an expected duration of anesthesia of >6 hours were allocated to either the glucose group, consisting of 40 patients who were infused with acetated Ringer’s solution with glucose (2 mg/kg/min), or the no glucose group, consisting of 40 patients who were infused with the same solution, but without glucose. After oxygenation, general anesthesia was induced with propofol, fentanyl, and rocuronium and was maintained with sevoflurane, oxygen, rocuronium, and remifentanil infusions. The rates of remifentanil infusion were titrated based on systolic arterial blood pressure, maintaining this parameter within 10% of its postanesthesia values. Seventy-four patients completed the study. Urinary 3-methylhistidine/creatinine (3-MH/Cre) ratio, acetoacetic acid, 3-hydroxybutyric acid, blood glucose, insulin, and cortisol were measured 3 times: at anesthesia induction (0 hour) and at 3 and 6 hours after anesthesia induction. Urinary 3-MH/Cre ratio was the primary study outcome. RESULTS:In the no glucose group, the urinary 3-MH/Cre ratio at 6 hours was increased compared with that at 0 hour (213 [range, 42–1903] vs 124 [18–672] nmol/&mgr;mol; the difference in medians, 89; the 95% confidence interval [CI] of the difference, 82–252; P = .0002). Acetoacetic acid and 3-hydroxybutyric acid levels in the no glucose group were greater than those in the glucose group at 6 hours (110 [8–1036] vs 11 [2–238] &mgr;mol/L; the difference in medians, 99; the 95% CI of the difference, 92–196; P < .0001 and 481 [15–2783] vs 19 [4–555] &mgr;mol/L; the difference in medians, 462; the 95% CI of the difference, 367–675; P < 0.0001, respectively). Blood glucose and insulin levels in the glucose group were greater than those in the no glucose group at 3 hours (146 [103–190] vs 93 [72–124] mg/dL; the difference in medians, 53; the 95% CI of the difference, 47–55; P < .0001 and 9.8 [1.2–25.4] vs 3.2 [0.4–15.0] &mgr;U/mL; the difference in medians, 6.5; the 95% CI of the difference, 4.8–6.8; P < .0001) and 6 hours (139 [92–189] vs 87 [68–126] mg/dL; the difference in medians, 52; the 95% CI of the difference, 44–58; P < .0001 and 8.1 [1.2–22.3] vs 3.2 [0.4–10.1] &mgr;U/mL; the difference in medians, 4.9; the 95% CI of the difference, 4.0–5.9; P < .0001). Cortisol levels in both groups were similarly within normal levels at 0, 3, and 6 hours. CONCLUSIONS:The study showed that intraoperative glucose infusion suppressed lipolysis and proteolysis in patients anesthetized with remifentanil in combination with sevoflurane during surgery of >6 hours in length.