Joho Tokumine

Changes in spinal GDNF, BDNF, and NT-3 expression after transient spinal cord ischemia in the rat

Previous studies have demonstrated that the expression of several growth factors including glial cell‐derived neurotrophic factor (GDNF), brain‐derived growth factor (BDNF), and neurotrophin‐3 (NT‐3) play an important role in defining neuronal survival after brain ischemia. In the present study, using a well‐defined model of transient spinal ischemia in rat, we characterized the changes in spinal GDNF, BDNF, and NT‐3 expression as defined by enzyme‐linked immunosorbent assay (ELISA) and immunofluorescence coupled with deconvolution microscopy. In control animals, baseline levels of GDNF, BDNF, and NT‐3 (74 ± 22, 3,600 ± 270, 593 ± 176 pg/g tissue, respectively) were measured. In the ischemic group, 6 min of spinal ischemia resulted in a biphasic response with increases in tissue GDNF and BDNF concentrations at the 2‐hr and 72‐hr points after ischemia. No significant differences in NT‐3 concentration were detected. Deconvolution analysis revealed that the initial increase in tissue GDNF concentration corresponded to a neuronal upregulation whereas the late peak seen at 72 hr corresponded with increased astrocyte‐derived GDNF synthesis. Increased expression of BDNF was seen in neurons, astrocytes, and oligodendrocytes. These data suggest that the early increase in neuronal GDNF/BDNF expression likely modulates neuronal resistance/recovery during the initial period of postischemic reflow. Increased astrocyte‐derived BDNF/GDNF expression corresponds with transient activation of astrocytes and may play an active role in neuronal plasticity after non‐injurious intervals of spinal ischemia.

Alveolar epithelial cells: differentiation and lung injury

Abstract:  Re‐epithelialization of alveolar epithelial cells is one of the important repair processes in many types of lung injury. The major functions of alveolar type II cells are synthesis and secretion of surfactant, hyperplasia in reaction to alveolar epithelial injury, and serving as progenitor cells for alveolar type I cells. The authors have examined the effects of several soluble factors on cultured alveolar type II cells in vitro, and also examined the histopathology and gene expression of surfactant proteins in the rat lungs with LPS, bleomycin and/or treated with keratinocyte growth factor. The authors next examined the effects of bone marrow stromal cells (BMSC) implanted transvenously into bleomycin‐induced lungs. The authors found that keratinocyte growth factor (KGF) is a strong growth factor for alveolar type II cells, and that KGF instillation prevents bleomycin‐induced lung injury. Furthermore, the authors showed the possibility of differentiation of implanted BMSC into alveolar epithelial cells. KGF and BMSC may play an important role in maintaining the alveolar epithelium and repairing the damaged epithelium after injury, and may well provide potential therapeutic alternatives.

Tissue necrosis caused by extravasated propofol.

To the editor: Clinical reports and animal studies have shown that extravasated propofol causes no serious sequelae [1–3]. However, we experienced a case in which accidentally extravasated propofol is likely to have caused necrosis of the forearm skin and muscle. A 37-year-old undernourished man with a history of alcohol abuse underwent an emergency operation (resection of the stomach and drainage of the abdominal cavity) for panperitonitis due to perforation of a gastric ulcer. Eleven days later, a reoperation was performed to stop the leakage in a lesion at the anastomosis of the stomach to the small intestine. After reoperation, the patient fell into septic shock, and continuous arteriovenous hemodialysis was instituted for acute renal failure. The patient was managed with a ventilator in the intensive care unit, and, for sedation, propofol (Diprivan) was administered continuously into the superficial vein on the palmar side of the right forearm through a 22-gauge cannula with 5% glucose solution. The amount of propofol administered ranged from 100 to 200 mg·h 1 (1.8–3.6mg·kg 1·h 1). No other medication was administered into this line. After 8 days of continuous infusion of propofol, phlebitis and swelling of the forearm were observed in the vein where propofol was administered. Because an extravasation of propofol was suspected, the venous line was removed. Propofol had been infused for approximately 12h at a rate of 150mg·h 1 (2.7 mg·kg 1·h 1) until the accidental extravasation of propofol became evident. Necrosis developed in the skin and muscle of the forearm (Fig. 1). The necrotic lesion was limited to the perivascular area. Although granulation at the margin of the necrotic lesion had been recognized 2 weeks later, the tissue under the necrosis had not recovered, and a skin defect ultimately remained. Three months after the onset of septic shock, the patient died from multiple organ failure. Although there have been several reports of extravasated propofol, this is the first report of a case in which extravasated propofol caused tissue necrosis. Propofol has been recognized to be a less invasive drug, because of its chemical properties, isotonicity, and neutral pH [4]. In previous reports of accidental extravasation [1,2] and intra-arterial injection [5–7] of propofol, propofol was harmless and did not induce any serious tissue damage. In this case, however, we could not find any cause of the tissue necrosis other than extravasated propofol. Although the general condition of this patient, including undernutrition and septic shock, was an important factor for skin necrosis by extravasation of propofol, we should be aware that extravasation of propofol can cause tissue necrosis.

The spinal GDNF level is increased after transient spinal cord ischemia in the rat.

Glial cell line-derived neurotrophic factor (GDNF) is known as the most potent neurotrophic factor against injury. We have characterized spinal GDNF changes after ischemia to clarify its possible physiological role against ischemic damage. Spinal ischemia in the rat was produced by cross-clamping of the thoracic aorta together with systemic hypotension. The spinal tissue GDNF level was measured by enzyme-linked immunoabsorbent assay (ELISA) and the localization of GDNF in the tissue was examined by immunohistochemistry. GDNF was increased reaching two peaks after ischemia. The first peak was at 2 hrs after onset of recirculation derived from alpha motor neurons. The second GDNF peak was at 72 hrs provided by astrocytes. These data suggest a necessity of GDNF to increase to protect against ischemic damage, and that activated astrocytes may have an important role in maintaining the GDNF level.

Dissection of the posterior wall by guide-wire during internal jugular vein catheterization

We report a case of posterior wall hematoma formation in the internal jugular vein after the puncture of central vein. An 82-year-old woman was scheduled for laparotomy for an abdominal incisional hernia. After induction of general anesthesia, we performed central venous catheterization via the right internal jugular vein under ultrasound guidance in the short-axis view and out-of plane technique. The ultrasound view after insertion of a guide-wire revealed a hematoma-like space on the posterior wall of the vein. We removed and reinserted the guide-wire. This time, insertion of the wire and catheter was uneventful. Seven days after the surgery, no hematoma-like space was found in the vein. The malposition of the guide-wire was detected before dilation, which enabled us to avoid complications in this case. We should note that the confirmation of guide-wire placement in the vein is important during ultrasound-guided central venous catheterization.

Unanticipated full stomach at anesthesia induction in a type I diabetic patient with asymptomatic gastroparesis

We encountered a case of unanticipated full stomach at anesthesia induction, despite a 12-h fasting period, in a type I diabetes patient with diabetic neuropathy presenting for elective vitrectomy for proliferative diabetic retinopathy. The patient had ingested seaweed 24 h prior to the surgery, and it was later found in the aspirated gastric content. Gastrointestinal dysfunction due to diabetic neuropathy and the high fiber content of the ingested seaweed are the probable causes of unanticipated full stomach in our case.

Appropriate method of administration of propofol, fentanyl, and ketamine for patient-controlled sedation and analgesia during extracorporeal shock-wave lithotripsy

AbstractPurpose. The aim of this study was to identify the appropriate method for administering propofol, fentanyl, and ketamine (PFK) for patient-controlled sedation and analgesia (PCSA) during extracorporeal shock-wave lithotripsy (ESWL). Methods. Twenty-one unpremedicated patients were randomly assigned to three groups that received different drug administration regimens. (group 1: low loading dose and high demand bolus, group 2: high loading dose and demand bolus, group 3: high loading dose and low demand bolus). Results. The patients in all groups were hemodynamically stable during ESWL. Oxygen desaturation was recognized in all groups, but was avoided by 2 l·min−1 of oxygen supply via a nasal prong. The total administration dose of the drugs was significantly higher (P < 0.05) in group 2 than in groups 1 and 3. The median level of sedation was the same, but the episodes of oversedation were not recognized in group 3 (P < 0.05). A significant difference in the frequency of episodes of oversedation was found between groups 2 and 3 (P < 0.05). The results were good or excellent for almost all patients, and were assessed as fair by only one patient in group 2. Conclusion. We concluded that the method used for group 3 is the most appropriate for administering PFK for PCSA during ESWL.

Quadratus lumborum block for femoral-femoral bypass graft placement: A case report.

Introduction:Atherosclerosis has a complex etiology that leads to arterial obstruction and often results in inadequate perfusion of the distal limbs. Patients with atherosclerosis can have severe complications of this condition, with widespread systemic manifestations, and the operations undertaken are often challenging for anesthesiologists. Case report:A 79-year-old woman with chronic heart failure and respiratory dysfunction presented with bilateral gangrene of the distal lower extremities with obstruction of the left common iliac artery due to atherosclerosis. Femoral–femoral bypass graft and bilateral foot amputations were planned. Spinal anesthesia failed due to severe scoliosis and deformed vertebrae. General anesthesia was induced after performing multiple nerve blocks including quadratus lumborum, sciatic nerve, femoral nerve, lateral femoral cutaneous nerve, and obturator nerve blocks. However, general anesthesia was abandoned because of deterioration in systemic perfusion. The surgery was completed; the patient remained comfortable and awake without the need for further analgesics. Conclusion:Quadratus lumborum block may be a useful anesthetic technique to perform femoral–femoral bypass.

Difficult Airway Due to an Undiagnosed Subglottic Tumor: A Case Report.

AbstractThe “cannot ventilate, cannot intubate” scenario during anesthesia induction can be lethal. We present a patient with an undiagnosed subglottic tumor who developed the “cannot ventilate, cannot intubate” situation after induction of general anesthesia, due to the presence of an undiagnosed subglottic tumor.A 93-year-old woman was brought to the operating room for repair of a femoral neck fracture. Both ventilation and intubation could not be accomplished, and the patient was awakened without complications after trials of maintaining the airway. In order to reverse muscle relaxation, sugammadex was useful to allow resumption of spontaneous breathing.A difficult airway can be caused by an undiagnosed subglottic tumor. Subglottic tumors can be misdiagnosed as asthma, because the clinical presentation can be very similar. If cricothyrotomy had been performed based on airway management algorithms, the airway may not have been controlled with a possibly fatal outcome. Ultrasound examination of the trachea may be useful to diagnose obstructive lesions in the airway.

A novel cannula-over-needle system for ultrasound-guided central venous catheterization

To the Editor: Ultrasound (US) guidance for central venous catheterization (CVC) is widely used to enhance patient safety and is performed using a needle alone or a needle/cannula combination [1]. The cannula may be difficult to image on US, as plastic weakly reflects the US signal. We developed a novel cannula-over-needle device (CV Legaforce EX, Terumo Co. Japan) to provide an easily visible, strongly reflected US signal that may facilitate US-guided CVC. Figure 1 shows the structure of the Legaforce EX. The purpose of this study was to evaluate the ability to image this new cannula-over-needle device using US imaging during CVC. We invited participants to engage in hands-on training for US-guided CVC. They were informed that their evaluation would be used in a research study. A needle or cannula/needle combination was inserted into a simulator (Real-vessel , Kyoto Kagaku Co. Japan) [2] at a 45 angle by a single nonparticipant to hide the identity of the device from the participant. We then compared visibility of the EX needle (EXN) and catheter (EXC) with the Legaforce SX needle (SXN) and catheter (SXC) (structure shown in Fig. 1). The SX devices have a standard smooth design. Participants evaluated US visibility of the devices on a scale from 1 (= invisible) to 10 (= clearly visible) on longitudinal views. Data were evaluated with the Kruskal– Wallis test for scores and the Mann–Whitney U test for comparing devices. A p value \0.05 was considered statistically significant. Nineteen people participated in this study, with longitudinal imaging of all devices. There were no differences between EXN (mean 7.4 ± 2.2) and SXN (5.5 ± 2.4, p [ 0.05). However, EXC (5.2 ± 2.5) was significantly more visible than SXC (3.2 ± 2.4, p \ 0.05). Using the combined needle/cannula combination, EX (6.9 ± 2.6) was significantly more visible than with SX (3.5 ± 2.5, p \ 0.05). The effectiveness of US to facilitate CVC and improve patient safety has been demonstrated [3]. Guidelines recommend the routine use of US [4, 5]. There are no specific recommendations regarding the type of needle and/or cannula that should be used. A novel device with improved US cannula visibility was developed (Fig. 1). The EX device was significantly more easily imaged on the longitudinal view than was the SX device, and was most pronounced with the cannula alone. Other tested combinations J. Tokumine (&) Department of Anesthesia, Seikei-kai Chiba Medical Center, Chiba, Japan e-mail: ii36469@wa2.so-net.ne.jp