Katsuyuki Terajima

Clinical role and efficacy of landiolol in the intensive care unit

Beta-adrenergic receptor blockers have proved to be effective for the management of various cardiovascular diseases and the prevention of perioperative cardiac events and cerebrovascular accidents. Landiolol is a short-acting beta-blocker, with high beta 1-selectivity and a short duration of action. We thought landiolol was valuable and suitable for intensive care unit (ICU) patients, and conducted a retrospective study. The records of 80 patients (58 post-surgical patients; group S and 22 internal medicine patients; group IM) were reviewed. Thirty-seven (64%) of the group S patients were post-coronary artery bypass graft surgery, and the IM group consisted mostly of patients with acute myocardial infarction. The most common indication for landiolol in group S was the prevention of myocardial ischemia (50%), and in group IM, it was atrial fibrillation (45%). The median infusion rate of landiolol was 5 μg·kg−1·min−1 and the median infusion time was 2 days. Twenty-six patients were continued on oral beta-adrenergic receptor blockers. Landiolol reduced heart rate significantly without reducing blood pressure, and stabilized hemodynamics. We confirmed that landiolol is valuable as a bridge to starting oral beta-adrenergic receptor blockers and as an anti-arrhythmic agent, and that it is suitable for ICU patients due to its high beta 1-selectivity and rapid onset and offset of action.

Fluid Resuscitation With Hemoglobin Vesicles In A Rabbit Model Of Acute Hemorrhagic Shock

ABSTRACT Several hemoglobin (Hb)-based oxygen carriers are available for use in clinical situations, but their use risks inducing cardiovascular dysfunction as a result of Hb interacting with nitric oxide. Hb vesicles (HbV) are liposome-encapsulated purified human Hb with polyethylene glycol chains at the surface. This study evaluated the effects of HbV on hemodynamics, tissue and systemic oxygenation, and osmotic pressure after fluid resuscitation in an acute hemorrhagic shock model. Hemorrhagic shock was induced in 24 anesthetized mechanically ventilated male rabbits by withdrawing blood to a mean arterial blood pressure (MAP) of 30 to 35 mmHg over 15 min and maintaining this state for 30 min. The animals were resuscitated by replacing the blood with equal volumes of HbV in recombinant human albumin solution (HbV/rHSA), rHSA alone, or Ringer lactated solution (RL), or with three times the withdrawn volume of RL and observed for 2 h. Fluid resuscitation restored MAP, central venous pressure, and cardiac index values, but these fell again within 2 h in rabbits treated with RL. Fluid resuscitation using HbV/rHSA immediately increased MAP and cardiac index but not systemic vascular resistance, maintained a high level of oxygen consumption, and reduced the blood glucose level, which increased after hemorrhage. Fluid resuscitation using HbV/rHSA did not disturb microoxygenation in the brain, kidneys, liver, or muscle; allowed an immediate recovery of tissue oxygenation without decreasing cardiac output or increasing systemic vascular resistance, and increased the oxygen consumption. HbV solution offers the advantages of systemic oxygenation without impairing microcirculation in the treatment of hemorrhagic shock.ABBREVIATIONS-BE, base excess; CI, cardiac index; CVP, central venous pressure; Hb, hemoglobin; HBOC, hemoglobin-based oxygen carrier; HbV, hemoglobin vesicles; MAP, mean arterial blood pressure; NO, nitric oxide; Po2, oxygen partial pressure; RBC, red blood cell; rHSA, recombinant human albumin solution; RL, Ringer lactated solution; SVR, systemic vascular resistance

Blood patch therapy for spontaneous intracranial hypotension: safe performance after epidurography in an unconscious patient.

IMPLICATIONS Epidurography was useful for identifying the epidural space and determining the likely spread of an epidural blood patch in an unconscious patient with spontaneous intracranial hypotension.

Myocardial dysfunction associated with proinflammatory cytokines after esophageal resection

Proinflammatory cytokines have been implicated in mediating myocardial dysfunction associated with major surgery. We investigated the profile of proinflammatory cytokines and the association of cytokine levels with myocardial function after esophagectomy. We studied 12 patients who underwent subtotal esophagectomy. One patient died of multiple organ failure. This patient had the largest interleukin-6 (IL-6) level of all the subjects. IL-6 levels increased from 14.9 ± 8.7 pg/mL to 498.4 ± 294.3 pg/mL (P < 0.05) at 6 h postoperatively. Interleukin-8 (IL-8) levels also significantly increased postoperatively. Right ventricular ejection fraction (RVEF) decreased from 44% ± 1% to 36% ± 2% (P < 0.05) and 37% ± 2% (P < 0.05) at 6 h and 12 h postoperatively. Stroke volume index (SVI) decreased significantly at the end of operation and at 6 h and 12 h postoperatively. The changes of RVEF and SVI showed an independent negative correlation with the IL-6 level (r = −0.70, P < 0.001 and r = −0.62, P < 0.001, respectively). In contrast, the change of RVEF and SVI was not correlated with the IL-8 level. Esophagectomy is associated with transient depression of myocardial function. IL-6 may contribute to this postoperative myocardial dysfunction. Implications We examined the association between myocardial function and proinflammatory cytokines after esophagectomy. Interleukin-6 may be the cytokine that most sensitively reflects the postoperative myocardial dysfunction.

Minor Cardiac Troponin T Release in Patients Undergoing Coronary Artery Bypass Graft Surgery on a Beating Heart

OBJECTIVES To determine whether and to what extent coronary artery bypass graft (CABG) surgery without extracorporeal circulation is associated with cardiac troponin T (TnT) release. DESIGN Prospective study. SETTING A single university hospital. PARTICIPANTS Twenty-three patients scheduled for minimally invasive CABG surgery. Sixteen patients received one coronary anastomosis, and seven received two. INTERVENTIONS TnT and creatine kinase-MB (CK-MB) levels were determined immediately before induction of anesthesia (baseline) and at 0, 12, and 24 hours after surgery. Hemodynamic measurements were made, and 5-lead electrocardiograms with continuous automated ST-segment trends were analyzed. MEASUREMENTS AND MAIN RESULTS All patients had a good cardiac outcome. Median cumulative coronary artery occlusion time was 27 minutes (range, 10 to 49 minutes). TnT levels were undetectable in 91.3% of patients at baseline when a detection limit of 0.01 ng/mL was employed. TnT and CK-MB showed significant elevations at 12 and 24 hours versus baseline. Postoperatively, TnT was detectable in 91.3% of patients, and 17.4% suffered minor myocardial damage, as evidenced by an abnormal increase in TnT greater than 0.2 ng/mL, excluding those exhibiting myocardial infarction. ST segment changes developed in seven patients, persisting for 13.0 minutes (range, 9.5 to 15.8 minutes) and disappearing immediately after coronary artery clamp release. There were no significant correlations between cumulative coronary occlusion time and peak TnT or CK-MB levels. CONCLUSIONS TnT was detected after surgery in most patients, and significant TnT levels indicative of myocardial injury (>0.2 ng/mL) were detected in only 17% of patients, probably as a result of brief periods of coronary artery occlusion.

Repeated dexmedetomidine infusions, a postoperative living-donor liver transplantation patient

Here we report on a postoperative living-donor liver transplantation (LDLT) patient who received nightly infusions of dexmedetomidine (DEX), a specific α2-adrenergic receptor agonist, to treat agitation and insomnia during an intensive care unit stay. The infusion rate was adjusted according to the Ramsay sedation score. The actual plasma concentrations were higher than the values predicted by RugLoop software package simulation 9 h after the DEX infusion. However, all of the measurements were within the therapeutic range for DEX. Thus, DEX infusion could be safely used in the postoperative LDLT patient by employing a simple consciousness scale.

What is the optimal dose of glucose administration during minor surgery under sevoflurane anesthesia

AbstractPurpose. We attempted to identify the optimal infusion rate of glucose to maintain an appropriate usage of energy sources during minor surgery after an overnight fast. Methods. Forty patients scheduled for tympanoplasty or skin grafting under sevoflurane anesthesia were assigned to four groups. The patients received a 2-h infusion of either saline or glucose at a rate of 0.1, 0.2, or 0.3 g·kg−1·h−1. Blood samples were collected before the induction of anesthesia, and at 1 and 2 h after the start of the saline or glucose infusion. Plasma glucose, free fatty acid, β-hydroxybutyrate, acetoacetate, and immunoreactive insulin were measured. Results. Plasma glucose concentration increased dose-dependently. Immunoreactive insulin levels increased in the groups receiving 0.2 or 0.3 g·kg−1·h−1 of glucose infusion. Free fatty acid and ketone bodies did not increase in any glucose infusion groups. The arterial ketone body ratio increased to over 1.00 in the groups receiving 0.2 or 0.3 g·kg−1·h−1 of glucose infusion. Glycorrhea was observed only in the group receiving 0.3 g·kg−1·h−1 of glucose. Conclusion. The smaller doses of glucose (0.1–0.2 g·kg−1·h−1) prevented lipolysis and hyperglycemia during minor surgery.

Unmasking of brugada syndrome by an antiarrhythmic drug in a patient with septic shock

Asymptomatic Brugada syndrome patients often display concealed Brugada-type electrocardiogram patterns that result in under-diagnosis of this syndrome. These patients include individuals of both genders and a wide range of ages. They are as likely as non-Brugada patients to have normal longevity or to suffer from a critical illness. Here we report a case of septic shock in which Brugada-type electrocardiogram patterns were induced by pilsicainide administration for the treatment of atrial fibrillation. This case report suggests that some drugs used in the treatment of septic shock can unmask the Brugada-type electrocardiogram pattern and induce lethal ventricular tachyarrhythmia.

A transient inflammatory reaction in the lung after experimental hemorrhagic shock and resuscitation with a hemoglobin-vesicles solution compared with rat RBC transfusion.

Transfusion for hemorrhagic shock can improve oxygenation, but immunoreactions may induce inflammation. Artificial oxygen carriers have been developed to address clinical concerns of infection and stability, but whether an artificial oxygen carrier might induce inflammation is not well known. To address this question, we compared inflammatory reactions after resuscitation with hemoglobin vesicles (HbVs) or red blood cells (RBCs) in a hemorrhagic shock rat model. Both HbVs and the stored and irradiated rat RBCs deprived of buffy coat were suspended in recombinant human serum albumin [(Hb) = 8.6 g/dL]. Under anesthesia, hemorrhagic shock was induced for 30 min, followed by resuscitation by 20 min transfusion of HbVs or rat RBCs in a volume equivalent to the volume of withdrawn blood. Lungs were excised 2 or 24 h after resuscitation, and mRNA levels of tumor necrosis factor alpha (TNF-&agr;), intercellular adhesion molecule-1 (ICAM-1), nitric oxide synthase 2 (iNOS), nitric oxide synthase 3, hypoxia-inducible factor 1 alpha, and heme oxygenase 1 (HO-1) were measured. In rats resuscitated with HbVs, mRNA levels of TNF-&agr; and HO-1 2 h after resuscitation were significantly higher than those in the rat RBC group, but the levels at 24 h were similar in both groups. The expression of iNOS and ICAM-1, second messengers of inflammation, was not affected, and inflammatory levels after 24 h with HbVs are similar to rat RBC transfusion. The rat RBC group did not show an expected inflammatory reaction related to a transfusion-induced lung injury, and a clinical relevance concerning this level of transient inflammatory reaction induced by HbVs is not known; however, attention to the early stage of resuscitation in ongoing studies of HbV is required.

Local Cardiac Wall Stabilization Influences the Reproducibility of Regional Wall Motion during Off-Pump Coronary Artery Bypass Surgery

Objective.Myocardial ischemia is a risk factor during off-pumpcoronary artery bypass procedures. The development of new regional wall motionabnormalities assessed by transesophageal echocardiography (TEE) is a verysensitive sign of myocardial ischemia. To facilitate anastomosis, theepicardial area of the anastomosis site is often immobilized by a“stabilizer.” This study was designed to investigate whethercardiac wall stabilization with an epicardial stabilizer could affect theinterpretation of wall motion during coronary anastomosis withoutcardiopulmonary bypass. Methods.The TEE videotapes of 15 adultpatients were investigated. Left ventricular (LV) transgastric short and longaxis views were divided according to a modified 16-segment method. LV wallmotion was scored using a 5-grade scale by two independent blindedinvestigators during pre-occlusion, occlusion, and reperfusion of anastomosedcoronary arteries. The wall motion scores of a stabilized segment combinedwith two adjacent segments were compared with those of non-stabilizedsegments. Interobserver agreement was assessed using the weighted kappastatistic. Results.A total of 216 segments were analyzed by twoinvestigators. The interobserver kappa coefficient in pre-occlusion andreperfusion periods was 0.87, 0.87 and 0.86, 0.87, respectively, indicatinghigh agreements without stabilizer. During the occlusion period in stabilizedand non-stabilized segments, it was 0.59 and 0.76, respectively, showingsignificantly less reproducibility in the presence of stabilizer.Conclusion.Cardiac wall stabilization affects the reproducibility inthe interpretation of regional wall motion during off-pump coronary arterybypass surgery. Caution should be used when monitoring for myocardial ischemiausing TEE during coronary artery bypass surgery with epicardial stabilizer.