Shigeru Saeki

Effects of presurgical local infiltration of bupivacaine in the surgical field on postsurgical wound pain in laparoscopic gynecologic examinations: a possible preemptive analgesic effect.

OBJECTIVE A randomized, double-blind, controlled study was designed to evaluate the effect of presurgical local infiltration of bupivacaine in the surgical field on postsurgical wound pain relief and analgesic requirements in 28 healthy patients scheduled for laparoscopic gynecologic examinations. INTERVENTIONS After induction of general anesthesia by routine methods, the patients were randomly divided into two groups. In the bupivacaine (B) group (n = 15), patients were injected with 5 ml of 0.25% bupivacaine at each incisional area (four sites, total of 20 ml) approximately 15 minutes before skin incision. In the control (C) group (n = 13), the surgical field was injected with an equal volume of physiologic saline solution (four sites, total of 20 ml). OUTCOME MEASURES Postsurgical wound pain at rest was evaluated by a 10-cm visual analog pain scale at 1, 10, 24, and 72 hours and 1 month after surgery. The patients were interviewed via telephone 1 month after hospital discharge for re-evaluation of resting pain. RESULTS The results indicated that the incidence of postsurgical wound pain for up to 10 hours after surgery in group B was significantly lower (p < 0.05) than in group C. Pain intensity ranged from mild to moderate (2-5 cm). In addition, the mean visual analog pain scale pain intensity was significantly less for group B (0.31 +/- 0.85 cm) than for group C (2.62 +/- 2.06 cm) for up to 10 hours after surgery (p < 0.05). The number of patients who requested analgesics and complained of sleep disturbances was significantly higher in group C (p < 0.05). The mean cumulative dose of diclofenac sodium at 24 hours was significantly (p < 0.05) lower in group B (6.67 +/- 17.6 mg) than in group C (30.8 +/- 25.3 mg). Prolonged postsurgical wound pain persisting 1 month after surgery was observed in one patient in group C. CONCLUSIONS It is concluded that presurgical infiltration of 0.25% bupivacaine in the surgical field is a useful method for decreasing postsurgical wound pain for up to 10 hours and analgesic consumption for up to 24 hours after laparoscopic gynecologic examination.

suppression of Nociceptive Responses by Spinal Mu Opioid Agonists : effects of Stimulus Intensity and Agonist Efficacy

To determine the influence of stimulation intensity on dose-response curves of three analgesics in halothane-anesthetized rats, continued immersion of the tail in 52.5 degrees C or 60 degrees C water for 15 s results first in a nociceptive reflex tail movement (tail flick = 2.8 +/- 0.4 s and 1.4 +/- 0.2 s, respectively), and a progressive increase in arterial blood pressure (delta BP = 21 +/- 1 and 24 +/- 1 mm Hg) and heart rate (delta HR = 27 +/- 2 and 32 +/- 2 beats/min). Intrathecally administered mu opioids, morphine (MOR), sufentanil (SUF), and [D-Ala2-N-Phe4,Gly-ol]-enkephalin (DAG), produced a dose-dependent inhibition of the tail flick and BP response with the relative activity being SUF = DAG > MOR. Although the magnitude of the response evoked by increasing stimulus intensity from 52.5 degrees C to 60 degrees C was increased only mildly (suggesting that both represented essentially supramaximal stimuli), this increase in stimulus intensity resulted in a significant rightward shift in the dose-response curves (decrease in apparent potency) of the three agonists, with the magnitude of the shift being MOR > SUF = DAG. Thus, the dose ratio (ED50 at 60 degrees C/ED50 at 52.5 degrees C) for these three analgesics given intrathecally on the tail flick and BP response was, respectively, 3.7 +/- 0.9 and 6500 +/- 465 for MOR; 0.5 +/- 0.9 and 2.4 +/- 0.9 for SUF; and 0.5 +/- 1.2 and 7.0 +/- 0.9 for DAG. Unlike SUF and DAG, with the 60 degrees C stimulus, the highest dose of MOR failed to abolish the BP and heart rate response. Previous work with an irreversible antagonist to define receptor occupancy requirements showed that the relative efficacy was SUF = DAG >> MOR. The present studies thus confirm the pharmacodynamically based prediction that for a given change in stimulus intensity, anesthetics with a high efficacy (DAG and SUF) show less shift in their dose response curves with a given increase in stimulus intensity than an agonist with low efficacy (MOR).

Effects of low-dose ketamine on neuropathic pain : An electroencephalogram-electrooculogram/behavioral study

Abstract The aim of the present study was to clarify the neurophysiological changes associated with analgesic and behavioral effects of low‐dose ketamine HCl in patients suffering from chronic neuropathic pain. Ten in‐patients with neuropathic pain participated in this single‐blind, placebo‐controlled study after giving written informed consent. Following intravenous injections of a saline solution (placebo), three bolus injections of 5 mg ketamine HCl were administered at 5 min intervals. Changes in pain perception were assessed using a numerical rating scale for pain. Behavioral changes, including psychotomimetic effects, were assessed using the Brief Psychiatric Rating Scale (BPRS). Electroencephalograms (EEG) and electrooculograms (EOG) were recorded continuously throughout the testing period. One minute EEG and closed‐eye eye movements were quantified. The effects of ketamine were evaluated by comparing the neurophysiological and behavioral parameters obtained from the placebo and ketamine trials. Pain reduction was significantly correlated with ketamine‐induced changes in hallucinatory behavior and excitement as measured by the BPRS. Ketamine injections caused a significant decrease in the EEGα amplitude without an accompanying reduction in EEG frequency. The EEGα amplitude reduction at the right central electrode was significantly related to subjective pain relief. Subanesthetic doses of ketamine significantly decreased rapid eye movements, but did not initiate slow eye movements. In conclusion, the present EEG‐EOG/behavioral results indicate that ketamine‐induced failure of neural integration between cortical–subcortical regions induces psychotic symptoms and alters pain perception on neuropathic pain.

The usefulness of intraoperative transesophageal echocardiography to identify the site of drainage of coronary artery fistula.

We present a patient with left main coronary artery to coronary sinus fistula in whom intraoperative transesophageal echocardiography (TEE) identified the precise location of the site of drainage of the fistula, which could not be accurately revealed with preoperative coronary arteriography, computed tomography, or transthoracic echocardiography. TEE was useful to confirm the absence of fistulous flow or new left ventricular regional wall motion abnormalities after fistula closure. We demonstrated the usefulness of intraoperative TEE in diagnosis and post-repair surgical evaluation for closure of coronary artery fistula (CAF). CAF is an infrequent vascular anomaly that establishes a direct link between an epicardial coronary artery and a cardiac chamber, major vessels, or other vascular structures (1,2). The most common sites of drainage are low-pressure structures such as the pulmonary artery, right ventricle, and right atrium (1,2). Although coronary arteriography is the “gold standard” for the diagnosis of CAF, it is not always possible to reveal the complete delineation of CAF, especially its drainage. We report a case of a 66-yr-old woman scheduled to undergo closure of CAF and coronary artery bypass grafts, in whom a CAF was found on preoperative arteriography originating from a dilated left main coronary artery. Preoperative exSupplemental data available at www.anesthesia-analgesia.org. Accepted for publication January 21, 2005. Address correspondence and reprint requests to Ryoji Iida, MD, PhD, Department of Anesthesiology, Surugadai Nihon University Hospital, 1-8-13 Kanda-Surugadai, Chiyoda-Ku, Tokyo 101-8309, Japan. Address e-mail to ryoiida@beach.ocn.ne.jp.

Infusion requirements and reversibility of rocuronium at the corrugator supercilii and adductor pollicis muscles.

Background: The aim of this study is to compare the infusion rates required to maintain a constant neuromuscular block and the reversibility of rocuronium at the corrugator supercilii muscle (CSM) and the adductor pollicis muscle (APM).

Vecuronium-induced neuromuscular blockade in a patient with cerebral palsy and hemiplegia

We evaluated vecuronium-induced neuromuscular block in both arms of a patient with cerebral palsy and hemiplegia. A remarkable resistance to vecuronium was observed in the hemiplegia side compared with cerebral palsy side. Complete recovery from neuromuscular block should be assessed in the cerebral palsy side that shows a delayed recovery.

Reflex Sympathetic Activity After Intravenous Administration of Midazolam in Anesthetized Cats

BACKGROUND:Although intrathecal midazolam has been reported to produce antinociceptive effects mediated by &ggr;-aminobutyric acid type A-benzodiazepine receptor complexes in the spinal cord, the effects of systemic midazolam on nociception remain unclear. We performed this study to examine the effects of IV-administered midazolam on somatosympathetic A&dgr; and C reflex discharges in brain-intact cats and decerebrate cats (with transection at midbrain level). METHODS:Somatosympathetic A&dgr;and C reflexes were elicited in the inferior cardiac sympathetic nerve by electrical stimulation of myelinated (A&dgr;) and unmyelinated (C) afferent fibers of the superficial peroneal nerve in 28 mature cats. After control somatosympathetic reflex responses were obtained, midazolam was administered IV to four groups of randomly allocated cats as follows: brain-intact cats at a dose of 0.03 mg/kg, brain-intact cats at a dose of 0.1 mg/kg, brain-intact cats at a dose of 0.5 mg/kg, and decerebrate cats at a dose of 0.1 mg/kg. RESULTS:C reflex discharges were significantly augmented at the dose of 0.03 mg/kg and significantly depressed at the dose of 0.1 and 0.5 mg/kg in brain-intact cats. C reflex discharges were also significantly depressed at the dose of 0.1 mg/kg in decerebrate cats. CONCLUSIONS:We have demonstrated that IV midazolam produces dose-related effects on somatosympathetic reflex discharges. The clinical implication of these findings is that the effect of midazolam on nociception depends on its dosage. It also appears that the infra-midbrain region plays a major role in mediating the depressive effects of midazolam on somatosympathetic C reflex discharges.

Parasympathetic nervous activity after administration of atropine and neostigmine using heart rate spectral analysis

Recently, heart rate spectral analysis has become recognized as a powerful tool for quantitatively evaluating autonomic nervous system activity. The purpose of this study was to analyze parasympathetic nervous activity by heart rate spectral analysis after administration of atropine and neostigmine for reversal of residual neuromuscular blockade. For our study, 36 female patients (26–37 years of age), ASA physical status (PS) I, who were scheduled for laparoscopic examination, were randomly allocated to one of the following four groups: In group A (1∶1), 9 patients received 1.0mg atropine followed 4 min later by 1.0 mg neostigmine. In group B (1∶2), 9 patients received 0.5 mg atropine followed 4 min later by 1.0 mg neostigmine. In group C (1∶2.5), 9 patients received 1.0 mg atropine followed 4 min later by 2.5 mg neostigmine. In group D (1∶2 mix), 9 patients received a mixed solution of atropine 0.5 mg and neostigmine 1.0mg. After finishing the laparoscopic examination, additional anesthesia was maintained with 70% nitrous oxide, 30% oxygen, and 0.5% isoflurane. The control data were obtained 10 min after finishing the laparoscopic examination. After that, the data on atropine were obtained between 2 and 4min after administration of atropine, and the data on neostigmine were obtained between 5 and 7 min after administration of neostigmine. We selected power spectral density of the high-frequency component (HF-p) in heart rate spectral analysis as an index to assess parasympathetic activity. In groups A, B, and C, the HF-p decreased after administration of atropine. In groups B and C, the HF-p increased after administration of neostigmine as compared to the control. In group A, the HF-p increased after neostigmine but did not differ from the control. The difference between groups D and B was not statistically significant. From the results of this study, we concluded that the muscarinic effect of neostigmine could not be sufficiently blocked by atropine at 1/2 dosages of neostigmine, but could be sufficiently blocked by atropine at equivalent dosages of neostigmine, under light isoflurane anesthesia.

Reactivation of Phantom Limb Pain Immediately after Cervical Spinal Decompression

IT is well known that phantom limb pain can reappear or be exacerbated transiently during spinal anesthesia in amputees. 1 However, to the best of our knowledge, the reappearance of phantom limb pain immediately after nonamputation surgery in an amputee has not been reported. We herein present a patient with chief complaint of reactivation of phantom limb pain the day immediately after cervical myelopathy surgery.

Comparative fading responses induced by mivacurium, cisatracurium, and d-tubocurarine in the evoked muscular compound action potentials of the cat

AbstractPurpose. It has been suggested that the different degrees of fade induced by nondepolarizing neuromuscular blocking agents in repetitive muscular contractions may be due to the varying affinities or binding kinetics of presynaptic nicotinic receptors. We compared the degree of fade induced by mivacurium, cisatracurium, and d-tubocurarine in the cat muscular compound action potential (mCAP). Methods. In 21 cats, mCAPs of the gastrocnemius muscle were evoked by paired (conditioning and test stimuli) and 2-Hz train-of-four (TOF) sciatic nerve stimulation. The interval between the paired stimuli was changed stepwise from 7 to 1000 ms. The ratios of the amplitude evoked by test stimulus to that evoked by the conditioning stimulus (M2/M1 ratios) and TOF ratios were measured. After baseline variables had been obtained, the cat received either mivacurium (0.08 mg·kg−1, n = 7), cisatracurium (0.05 mg·kg−1, n = 7), or d-tubocurarine (0.5 mg·kg−1, n = 7). A series of M2/M1 ratios and TOF ratios were measured at various levels of partial block during recovery. Results. At 10% of baseline amplitude, all agents significantly depressed the M2/M1 ratios (i.e., fade) at relatively longer intervals of paired stimuli (mivacurium, ≥100 ms; cisatracurium, ≥40 ms; and d-tubocurarine, ≥20 ms), when compared with baseline. The order of activity to produce fade was mivacurium < cisatracurium < d-tubocurarine. A similar result was obtained in TOF ratios measured at various levels of neuromuscular block. Conclusion. Our results suggest that mivacurium shows a lesser degree of fade during partial neuromuscular block than cisatracurium and d-tubocurarine.