Kazunori Yamashita

Preoperative administration of intravenous flurbiprofen axetil reduces postoperative pain for spinal fusion surgery.

PurposeThe aim of the study was to investigate postoperative analgesia and the opioid-sparing effect of the preoperative administration of intravenous flurbiprofen axetil in patients undergoing spinal fusion surgery.MethodsThirty-six patients were randomly allocated into one of three groups. Group A received preoperative flurbiprofen axetil, 1 mg·kg−1. Group B received postoperative flurbiprofen axetil, 1 mg·kg−1. Group C received a placebo. All groups were given a standardized anesthesia and intravenous morphine via a patient-controlled analgesia device for postoperative analgesia. The pain score was evaluated by a visual analog scale (VAS) at 0 (T0), 1 (T1), 2 (T2), 6 (T3), 12 (T4), and 24 (T5) h after surgery, and the morphine requirement was recorded during the study period.ResultsVAS in group A was significantly lower than that in group B at T0 and T1. VAS in group A was significantly lower than that in group C throughout the time course after surgery. Postoperative morphine consumption in group A was significantly lower than that in groups B and C at T0 to T3.ConclusionAs compared with postoperative administration, preoperative administration of intravenous flurbiprofen axetil provides better postoperative analgesia and an opioid-sparing effect in patients undergoing spinal fusion surgery under general anesthesia.

Increased incidence of emergency airway management after combined anterior-posterior cervical spine surgery.

Among some kinds of cervical spine surgeries, combined anterior-posterior cervical spine surgery (CAP-CS surgery) requires prolonged operative time and highly invasive procedure. This study was performed to determine whether CAP-CS surgery was associated with increased risk of emergency airway management compared with other cervical spine surgeries (O-CS surgeries). The records of the patients who underwent cervical spine surgery between July 2001 and March 2003 at our institution were reviewed retrospectively, and we determined whether the CAP-CS surgery was associated with an increased risk of emergency airway management in comparison with O-CS surgeries, using the logistic regression analysis. A total of 165 were eligible for inclusion in the study. A total of 127, 20, 11, 5, and 2 patients suffered from cervical myelopathy, traumatic cervical spinal cord injury, atlantoaxial dislocation, cervical spinal tumors, and cervical pyogenic spondylitis, respectively. The operative approaches were CAP-CS surgery, anterior surgery, posterior surgery, and atlantoaxial surgery in 10, 56, 88, and 11 patients, respectively. Thus, the operative approaches were CAP-CS surgery in 10 patients and O-CS surgeries in 155 patients. Postoperative emergency airway management was required in 7 of the 10 patients (70%) who underwent CAP-CS surgery, and 2 of the 155 patients (1%) who underwent O-CS surgeries. The increased risk of postoperative emergency airway management imposed by CAP-CS surgery was 178.5 by an odds ratio, with a 95% confidence interval of 25.6 to 1246. The results show that CAP-CS surgery provides a major risk factor for postoperative emergency airway management.

Influence of low-molecular-weight hydroxyethyl starch on microvascular permeability in patients undergoing abdominal surgery : comparison with crystalloid

PurposeAdequate volume therapy is essential for stable hemodynamics and sufficient urinary output perioperatively. Hydroxyethyl starch (HES) has been reported to attenuate the microvascular hyperpermeability which occasionally occurs in surgical patients. This study was carried out to evaluate the effect of low-molecular-weight HES on the urinary microalbumin/creatinine ratio (MACR), a marker of microvascular permeability, in surgical patients.MethodsIn a prospective, controlled, and randomized clinical trial, 21 patients undergoing abdominal surgery were divided into two groups. Group HES (n = 10) received HES at 2 ml·kg−1·h−1 during surgery and at 1 ml·kg−1·h−1 after surgery, and additionally they received acetated Ringer’s solution (AR) at a rate to keep central venous pressure (CVP) 5 mm Hg. Group AR (n = 11) received AR at a rate to keep CVP at 3–5 mmHg. MACR, soluble intercellular adhesion molecule-1 (sICAM-1), and urinary output were measured intermittently in the perioperative period.ResultsMACR was significantly increased during surgery in both groups. There was no significant difference in MACR between the two groups throughout the study period. The serum concentration of sICAM-1 decreased during surgery in both groups, and that in group HES was significantly lower than that in group AR at the end of surgery. Postoperative urinary output in group HES was greater than that in group AR. The intensive care unit (ICU) stay in group HES was shorter than that in group AR.ConclusionAlthough low-molecular-weight HES does not improve microvascular hyperpermeability, the expansion of the intravascular volume by HES results in higher urinary output in the postoperative period than that seen with crystalloid solution. The lower concentration of sICAM-1 after surgery may be due to hemodilution.

Postoperative analgesic effect of preoperative intravenous flurbiprofen in arthroscopic rotator cuff repair

PurposeThis study was carried out to evaluate the postoperative analgesic effects of preoperative intravenous flurbiprofen in patients undergoing arthroscopic rotator cuff repair under general anesthesia.MethodsWe studied 44 patients who underwent an elective arthroscopic rotator cuff repair in a prospective, randomized, and double-blind fashion. The patients were divided into two groups. Group A (n = 22) received lipid emulsion 0.1 ml·kg−1 as a placebo, and group B (n = 22) received flurbiprofen 1 mg·kg−1 before the surgery. Intralipid or flurbiprofen was given intravenously 5 min before the surgery. General anesthesia was maintained with sevoflurane and nitrous oxide, and 10 ml of 0.75% ropivacaine was administered intraarticularly at the end of the surgery. Postoperative analgesia was supplied with intravenous 0.1 mg buprenorphine according to the patient’s demand. The effectiveness of flurbiprofen’s analgesic effect was measured by a visual analog scale (VAS) and by the amount of buprenorphine consumption at 0.5, 1, 2, 4, 6, 12, and 24 h after the surgery. Time to the first analgesic was also recorded.ResultsVAS in group B was significantly (P < 0.01) lower than that in group A during the first 6 h postoperatively. The amount of buprenorphine consumption in group B was also significantly (P < 0.01) less than that in group A within the first 2 h postoperatively. The time to first analgesic request in group B was significantly (P < 0.01) longer than that in group A.ConclusionThese results show that preoperative intravenous flurbiprofen facilitates the analgesic effect in the early postoperative period after arthroscopic rotator cuff repair.

Age-dependent relationship between bispectral index and sedation level

STUDY OBJECTIVE To determine the relationship between bispectral index (BIS) and sedation. DESIGN Prospective, observational clinical study. SETTING Intensive care unit of a public hospital in Japan. PATIENTS 22 ASA physical status I, II, and III middle-aged (18-65 yrs) and elderly (>65 yrs) patients receiving postoperative sedation with midazolam. INTERVENTIONS Patients were allocated to two groups: Group M was composed of middle-aged patients (<65 yrs) and Group H elderly patients (>65 yrs). Midazolam was administered at a bolus dose of 0.1 mg/kg, followed by a continuous dose of 0.04 mg/kg per hour, which was adjusted every two hours to achieve a target level of sedation at 3-6 on the Ramsay Sedation Scale (RSS); buprenorphine was administered at a constant rate (0.625 microg kg(-1) hr(-1)). MEASUREMENTS BIS value, RSS, midazolam dose, body temperature (BT), heart rate, dopamine dose, and mean arterial pressure were recorded every two hours by an independent nurse. Data were analyzed using Spearman rank correlation and the Mann-Whitney U test. MAIN RESULTS BIS values decreased depending on depth of sedation; a significant correlation was noted between groups in RSS and BIS. The BIS values at levels of RSS 5 and 6 were significantly lower in Group H than Group M. CONCLUSION BIS correlated with sedation depth, with BIS scores in group H than group M at a deep sedation depth.

Postoperative analgesia with minidose intrathecal morphine for bipolar hip prosthesis in extremely elderly patients.

PurposeIt is known that an optimal dose of intrathecal morphine for analgesia after total hip arthroplasty in older patients is 0.1 mg. On the other hand, minidose intrathecal morphine (0.05 mg) is useful for analgesia after the transurethral resection of the prostate in elderly patients. We evaluated the postoperative analgesic effect of minidose intrathecal morphine after bipolar hip prosthesis in seniors (age 85 years or more) undergoing spinal anesthesia.MethodsTwenty seniors undergoing bipolar hip prosthesis under spinal anesthesia were randomly allocated to one of two groups. Group A (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, and group B (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, plus morphine, 0.05 mg. Pain, nausea, and itching were evaluated using a numerical rating scale, ranging from 0 to 10, at 0, 4, 8, 12, and 24 h after the operation.ResultsThe values on the numerical rating scale for pain in group B were significantly lower than those in group A at 4, 8, and 12 h after the operation. There were no significant differences between the groups in the values on the numerical rating scale for nausea or itching throughout the time course of the study. No patient in either group showed hypoxemia or respiratory depression throughout the time course.ConclusionThe results show that minidose intrathecal morphine provides a good analgesic effect without side effects, and it would be an effective and safe procedure for bipolar hip prosthesis in seniors.

Preadministration of low-dose ketamine reduces tourniquet pain in healthy volunteers

We evaluated whether preadministration of low-dose ketamine could attenuate tourniquet pain and arterial pressure increase using high tourniquet pressure in ten healthy awake volunteers. Ketamine, 0.1 mg·kg−1, or normal saline was given intravenously in a double-blind fashion before tourniquet inflation with a pressure of 400 mmHg at the thigh. Visual analog scale (VAS) scores and systolic blood pressure (SBP) were measured at 5-min intervals. Ketamine significantly reduced VAS scores compared to saline just after tourniquet inflation [90 (64–100) mm, median (range), with saline versus 66 (50–81) mm with ketamine, P < 0.01] and at 30 min [92 (61–100) mm with saline versus 70 (50–100) mm with ketamine, P < 0.03), and significantly prolonged tourniquet time (28 ± 6 min with saline, mean ± SD, versus 37 ± 7 min with ketamine, P < 0.01). SBP (120 ± 9 mmHg) significantly increased before tourniquet deflation (133 ± 16 mmHg) in the saline trial, but not in the ketamine trial. The results show that preadministration of low-dose ketamine attenuates tourniquet pain and arterial pressure increase during high-pressure tourniquet application and prolongs tourniquet time in healthy volunteers.

Comparative efficacy of ropivacaine and bupivacaine for epidural block in outpatients with degenerative spinal disease and low back pain

Abstract Background and objectives: It is known that ropivacaine produces a differential block for sensory and motor nerves with lower toxic potential than bupivacaine. This study was carried out to evaluate the comparative efficacy of ropivacaine and bupivacaine for lumbar epidural block in 16 outpatients with degenerative spinal disease. Methods: The study was performed in a prospective, randomized, double blind and crossover fashion. A single injection of 8 ml of 0.375% or 0.2% ropivacaine or 0.25% bupivacaine was given at the L4-5 interspace. Each subject received all of the test solutions at an interval of one week or more. The upper level of analgesia, pain and motor blockade were evaluated by pin prick, visual analogue scale (VAS), and Bromage scale, respectively, and the recovery times to mobilization, ambulation and spontaneous micturition were measured. Results: There was no significant difference in the upper level of analgesia and the reduction of VAS among the three trials. Bromage scale with...

Malignant hyperthermia susceptibility diagnosed with a family-specific ryanodine receptor gene type 1 mutation.

Malignant hyperthermia (MH) is an autosomal dominant disorder of skeletal muscle calcium regulation, and the rate of calcium-induced calcium release (CICR), determined by using skinned fibers of skeletal muscle, has been employed as a diagnostic test for MH susceptibility in Japan. The ryanodine receptor (RYR1), encoding the major calcium-release channel in skeletal muscle sarcoplasmic reticulum, has been shown to be mutated in a number of MH pedigrees. We experienced the detection of accelerated CICR and/or an RYR1 mutation in a patient with an MH episode and his family. Accelerated CICR and an RYR1 mutation (c.14512C>G, p.L4838V) were found in the patient and his father. The MH-causative mutation (c.14512C>G, p.L4838V) was also found in his brother and his son (resulting in the diagnosis of MH without the CICR test), but the mutation was not found in his mother or two daughters. With the detection of the family-specific mutation in other family members, the diagnosis of MH was made without the invasive CICR test.

Landiolol, a new ultra-short-acting β1-blocker, reduces anaesthetic requirement during sevoflurane/N2O/fentanyl anaesthesia in surgical patients

Background and objective It is known that esmolol, a short-acting β1-blocker, reduces anaesthetic requirement. In this study, we evaluated whether a low dose of landiolol, a new ultra-short-acting β1-blocker, can reduce the sevoflurane requirement. Methods Twenty-five patients undergoing hip surgery were randomly divided into two groups. Group A (n = 13) received landiolol (bolus injection of 0.031 mg· kg−1 and continuous infusion at a rate of 0.01 mg·kg−1·min−1). Group B (n = 12) received physiological saline. Landiolol and physiological saline were started before the induction of anaesthesia and continued until the end of anaesthesia. Anaesthesia was maintained with sevoflurane, 60% N2O and fentanyl. Sevoflurane concentration was controlled to keep the bispectral index at approximately 50. The end-tidal sevoflurane concentration and haemodynamics were measured during anaesthesia. Results The average end-tidal sevoflurane concentration in group A was significantly lower than that in group B (1.2 ± 0.30 vs. 1.8 ± 0.3%, P < 0.01). Maximum values of systolic arterial pressure showed no difference between the groups, whereas the maximum value of heart rate in group A was significantly less than that in group B (61 ± 10 vs. 76 ± 14 beats min−1, P < 0.05). Conclusion The results suggest that a low dose of landiolol significantly reduces the intraoperative sevoflurane requirement during sevoflurane/N2O/fentanyl anaesthesia in patients undergoing hip surgery.