Junichi Ikegaki

The effect of diltiazem on the cardiovascular response to tracheal intubation

The efficacy of diltiazem in the attenuation of the cardiovascular response to laryngoscopy and tracheal intubation was studied in patients who received 0.2 or 0.3 mg/kg diltiazem 60 seconds before the start of laryngoscopy. These data were compared with a control group who received saline. Each group consisted of 10 patients who had elective surgery. Patients who received saline showed a significant increase in mean arterial pressure and rate pressure product associated with tracheal intubation. These increases after tracheal intubation were reduced in diltiazem‐treated patients compared with those of the control group (p < 0.05). The data suggest that a bolus injection of diltiazem is a simple, practical and effective method to attenuate the hypertensive response to laryngoscopy and tracheal intubation.

Effects of prostaglandin E1 on the cardiovascular response to tracheal intubation

STUDY OBJECTIVE To evaluate the efficacy of prostaglandin E1 in attenuating the hypertensive response to laryngoscopy and intubation. DESIGN Controlled, comparative, and randomized study. SETTING Induction of anesthesia for elective surgery at a university hospital. PATIENTS Thirty normotensive patients (ASA physical status I) undergoing elective surgery divided into three groups. Each group consisted of ten patients. INTERVENTIONS Anesthesia was induced with thiopental sodium 5 mg/kg intravenously, and tracheal intubation was facilitated with vecuronium 0.2 mg/kg. Either 0.3 micrograms/kg of prostaglandin E1, 0.6 micrograms/kg of prostaglandin E1, or saline (control) was injected 15 seconds before starting direct laryngoscopy (within 30 seconds), which was attempted 2 minutes after administration of thiopental sodium and vecuronium. MEASUREMENTS AND MAIN RESULTS Patients receiving saline showed a significant increase in mean arterial pressure and rate-pressure product associated with tracheal intubation. These increases following tracheal intubation were significantly less in prostaglandin E1-treated patients than in the control group (p less than 0.05). CONCLUSIONS A single rapid intravenous administration of prostaglandin E1 is a practical pharmacologic and safe method to attenuate the hypertensive response to tracheal intubation. The use of 0.6 micrograms/kg of prostaglandin E1 as a supplement during induction is recommended for reducing the pressor response to intubation on the basis of rate-pressure product and mean arterial pressure following intubation as an index.

A single lobal inflation technique using bronchofiberoptic jet ventilation during video-assisted thoracoscopic surgery for bullae.

ideal setting in which preoperative assessments are completed. The benefits of OPE are indeed obvious enough to motivate the surgeons to change from their outdated routines (i.e., to discontinue unnecessary admissions as a manifestation of the surgeon’s trust in the anesthesiologist’s assessments). Dr. Pollard states that the beneficial effects of OPE would have been higher when we had agreed to evaluate future inpatients only if the plan was to admit them on the actual day of surgery. However, we did not make such agreements, because in our opinion, in principle, each potential inpatient can be admitted on the day of surgery. Only a small percentage of patients should be admitted one or more days before surgery, typically based on the patients’ health condition (e.g., severe chronic obstructive pulmonary disease that requires IV medication for optimization). This decision to admit patients before the day of surgery should be made by the anesthesiologist at the OPE clinic, after completion of the preoperative health assessment. Furthermore, in the Dutch setting, the anesthesiologist does not have the authority to compel surgeons to admit patients at the day of surgery. Anesthesiology departments can only strongly recommend the authorities (whether these are surgeons, hospital boards, or insurance companies) to admit patients at the day of surgery to achieve the optimal benefits of OPE, both from a medical and a financial perspective. Finally, if we would evaluate only those patients at the OPE clinic, who are admitted by the surgeon on the actual day of surgery, the patients who might benefit most from OPE (those who the surgeon considered admitting before the day of surgery) would not be evaluated at the OPE clinic. These patients then have to be assessed the afternoon before surgery, a policy that has been demonstrated to be less costeffective, resulting again in late operating room cancellations and inappropriate additional testing by surgical residents “to satisfy the anesthesiologist.” In conclusion, in our opinion each potential surgical inpatient is a candidate for admission on the day of surgery and should therefore be evaluated at the OPE clinic some weeks before surgery. The specialist in perioperative care (i.e. the anesthesiologist) should agree with the surgical specialist to admit patients before the day of surgery only for reasons of optimization of concurrent diseases.

Perioperative effect of methylprednisolone given during lung surgery on plasma concentrations of C3a and C5a.

Methylprednisolone or saline (placebo) solution was infused intravenously in 28 patients undergoing elective lobectomy for lung cancer. The state of the complement system during and after surgery and the effects of methylprednisolone on biologically active products of complement were studied by measurements of plasma C3a and C5a anaphylatoxins and leukocyte counts in peripheral blood perioperatively. In the placebo group plasma concentrations of C3a were significantly increased on postoperative days 1 and 2, whereas C5a had risen significantly 6 hours after surgery and on days 1 and 2. Methylprednisolone infusion during surgery eliminated the postoperative elevation of C3a and C5a. The postoperative leukocyte count in peripheral blood was higher in the methylprednisolone group than in the controls. The observations indicated that methylprednisolone may reduce the influx of leukocytes from peripheral blood into the airways by attenuating production of biologically active complements.

Effects of surfactant on lung injury induced by hyperoxia and mechanical ventilation in rabbits.

We evaluated the effects of exogenous surfactant on lung injury caused by 100% oxygen and mechanical ventilation in rabbits. Surfactant-treated rabbits (n=9) were ventilated with 100% oxygen for 36 hours and bovine surfactant was given via the trachea 12 hours after the start of mechanical ventilation. Saline-treated (n=9) rabbits were treated identically, except that they received saline without surfactant. There were no significant changes in hemodynamics, lung mechanics, or arterial oxygen tension during artificial ventilation.Albumin concentration in the bronchoalveolar lavage fluid (BALF) of saline-treated rabbits was slightly higher than those in surfactanttreated rabbits and significantly higher than in non-treated rabbits. C3a concentration in BALF was significantly higher in saline-treated rabbits than in surfactant-treated and non-treated rabbits. In addition, the wet-to-dry lung weight ratio was significantly lower in surfactanttreated rabbits than in saline-treated rabbits (5.06±0.10 vs. 5.67±0.14,P<0.05).Light microscopy revealed hyaline membrane formation in saline-, treated rabbits, but fewer changes were observed in surfactant-treated rabbits. Electron microscopy revealed extensive endothelial cell destruction in saline-treated rabbits, while such changes except endothelial cell swelling were not observed in surfactant-treated rabbits.We conclude that exogenous surfactant attenuated lung injury caused by oxygen exposure and ventilation.

Peri‐operative changes in plasma C3a and C5a concentrations in infants

It is well known that complement activation plays a key role in the development of pulmonary insufficiency; it is also well known that cortisol suppresses complement activation. By measuring the plasma concentrations of C3a and C5a, we investigated peri‐operative changes in the activation of the complement system in 18 infants undergoing elective abdominal surgery. We also measured plasma cortisol concentrations to assess the peri‐operative relationship between complement activation and the stress produced by multiple peri‐operative factors following two anaesthetic techniques. Eighteen infants ranging in age from 1 to 11 months were randomly divided into two groups according to the anaesthetic technique used: Group 1 consisted of nine infants in whom general anaesthesia was maintained with halothane and nitrous oxide (N2O) in oxygen, while Group 2 consisted of nine infants in whom general anaesthesia was maintained with fentanyl and N2O in oxygen. Plasma C3a and C5a concentrations were higher in the fentanyl group than in the halothane group during the peri‐operative period. Plasma cortisol concentration, in contrast, was lower in the fentanyl group both during and after surgery. The post‐operative clinical course showed no significant intergroup differences between the two groups throughout the study. These observations suggest that the difference in peri‐operative complement activation between the halothane and the fentanyl groups may have been due, in part, to different peri‐operative stress responses. However, further studies are required to elucidate the precise causative mechanisms and the clinical implications of complement activation in infants.

Ten years of successful pain management for complex regional pain syndrome by epidural anesthesia with implanted port: a case report.

To the Editor: A 27-year-old woman underwent tumor resection for fibrous dysplasia of the right ilium. Following surgery, she suffered from burning pain, allodynia, edema, cutaneous atrophy, and bilateral difference of skin temperature in the territory of the right lateral femoral cutaneous nerve. Her pain was diagnosed as complex regional pain syndrome (CRPS) associated with injury to the lateral femoral cutaneous nerve. The numeric rating scale (NRS) was 8–9. Temporary pain relief could be achieved with oral tramadol hydrochloride administration or a single epidural block, but this was insufficient. Spinal cord stimulation system (SCS) implantation was performed through placement of a dual electrode lead in the epidural space [1, 2]. However, pain relief by SCS was only partial, and the patient wished to avoid frequent epidural blocks, as the pain relief varied each time (NRS 3–7). Dural puncture headaches were also a patient concern, given her prior experience with a severe post dural puncture headache following spinal anesthesia. After clearly explaining the risk of infection to our patient, we implanted an epidural port (PORT-A-CATH; Smiths Medical, UK) from L2–L3 to the extremity to T12. Following implantation, we administered weekly doses of either 6 or 7 ml 1 % mepivacaine, which yielded significant pain relief for years with NRS 3–4. After 6 years after implantation, we changed the local anesthetic to 0.75 % ropivacaine, leading to the decrease of the NRS to 1–2. We adjusted the dose of local anesthetics according to pain control for the patient. In the 10 years since implantation, the epidural catheter has broken twice (after 3 years and 7 months, and at 8 years and 3 months following implantation). Catheter breakage was confirmed by contrast agent leakage, and catheter replacement under general anesthesia was uneventful in both instances. Epidural catheter implantation is often performed for cancer patients with intractable pain [3, 4], but our report suggests that it may also serve as an alternative treatment to address CRPS that is nonresponsive to medication or SCS.