Tamotsu Kuniyoshi

Three cases of suspected sugammadex-induced hypersensitivity reactions.

Neuromuscular blocking agents have been implicated in 60-70% of anaphylactic events associated with anaesthesia. We report two cases of probable hypersensitivity reaction to sugammadex and an additional suspected but less supported case of possible immune-mediated reaction or other adverse reaction. The patients were given a bolus of sugammadex 100 mg immediately before extubation. In all three patients, a possible allergic reaction was suspected within 4 min of sugammadex administration, but with different degrees of severity. Skin testing was positive in two of these patients. Hypersensitivity to sugammadex unaccompanied by cardiovascular or respiratory symptoms might be missed during the course of anaesthesia. Careful monitoring for possible allergic responses is required in patients who have received sugammadex.

Impact of skin incision on the pleth variability index.

ObjectiveThe pleth variability index (PVI), which is calculated from respiratory variations in the perfusion index (PI), reportedly predicts fluid responsiveness. However, vasomotor tone fluctuations induced by nociceptive stimuli change the PI and may reduce the accuracy of PVI. The aim of this study was to confirm the effects of surgical stimuli on PVI.MethodsTwenty-four patients were examined after the induction of general anesthesia. Heart rate (HR), mean arterial blood pressure (MBP), PI, PVI, stroke volume variation (SVV), and cardiac index (CI) were recorded before and after the skin incision. PI and PVI were calculated using a Radical 7 pulse oximeter, and SVV and CI were calculated using the FloTrac/Vigileo system.ResultsAfter the skin incision, the PI decreased significantly from 5.3 (4.0–6.2%) to 3.6% (1.8–4.7%), whereas the PVI increased significantly from 9.5 (7.0–12.0%) to 13.5% (9.0–16.0%). A significant negative correlation was observed between the changes in PI and PVI before and after the skin incision. The skin incision did not affect the HR, CI, or SVV but increased the MBP.ConclusionThis study showed a significant increase in the PVI and a negative correlation between the changes in PVI and PI before and after the skin incision. The PVI can be calculated from the variations in the PI caused not by mechanical ventilation, but rather by fluctuations in vasomotor tone. When using the PVI as an indicator for fluid responsiveness, it is crucial to pay attention to fluctuations in vasomotor tone induced by nociceptive stimuli.

Effects of olprinone on hepatosplanchnic circulation and mitochondrial oxidation in a porcine model of endotoxemia

PurposeThis study was performed in order to assess the effects of olprinone, a phosphodiesterase III inhibitor, on hepatic oxygen delivery (DO2H), oxygen consumption (VO2H), and mitochondrial oxidation in the liver of a porcine endotoxemia model.MethodsFourteen pigs received continuous infusion of endotoxin via the portal vein for 240 min. From t = 150 to t = 240 min, animals were randomly divided into two groups to receive saline (control [CONT]; n = 7), or olprinone (OLP; n = 7) via the central vein.ResultsIn the OLP group, prior to olprinone treatment at 150 min, endotoxin induced significant decreases in the cardiac index (CI; from 120 ± 31 to 65 ± 13 ml·kg−1·min−1; P < 0.01) and DO2H (from 3.58 ± 0.81 to 1.55 ± 0.49 ml·kg−1·min−1; P < 0.01), while VO2H was maintained. After administration of olprinone (from t = 150 to t = 240 min), CI was unchanged, while DO2H increased from 1.55 ± 0.49 to 1.93 ± 0.38 ml·kg−1·min−1 (P < 0.01) and VO2H increased from 0.42 ± 0.28 to 0.69 ± 0.38 ml·kg−1·min−1 (P < 0.01). At t = 240 min, the oxidation level of cytochrome aa3 was significantly higher in the OLP group than in the CONT group (OLP, 66.2 ± 19.3% vs CONT, 26.4 ± 17.3%; P < 0.01).ConclusionOur data for this porcine endotoxemia model suggest that olprinone may have beneficial therapeutic effects in restoring not only systemic and hepatic circulation but also mitochondrial oxidation in the liver.

Relationship between Redox Behavior of Brain Cytochrome Oxidase and Neurological Prognosis

Currently, no on-line method of assessing cerebral oxygenation is sufficiently accurate to be clinically helpful. In an attempt to find a good predictor of postoperative cerebral outcome, we retrospectively studied the relationship between the redox behavior of cytochrome oxidase (cyt. ox.) during an operation and the neurological prognosis in 83 patients who underwent thoracic aortic surgery. Our data revealed three patterns of change in the redox behavior of cyt. ox. during the operation; the actual pattern exhibited by a given patient showed a highly significant correlation with the neurological prognosis (p < 0.0001). We conclude that the redox behavior of cyt. ox. during an operation is likely to be a good predictor of postoperative cerebral outcome, which implies that brain tissue oxygen sufficiency can be evaluated by near-infrared measurement of cytochrome oxidase (except for that in local regions far from the monitoring site).

Systematic evaluation of nitric oxide, tetrahydrobiopterin, and anandamide levels in a porcine model of endotoxemia

PurposeUsing a lipopolysaccharide (LPS)-treated porcine model, we examined: (1) whether nitric oxide (NO), anandamide, and tetrahydrobiopterin (BH4) increased or not in early endotoxic shock; and (2) the location of the major site of production of these molecules, by comparing their concentrations in arteries and the portal and hepatic veins.MethodsTen pigs received an infusion of LPS at 1.7 μg·kg−1·h−1 via the portal vein for 240 min. Consecutive changes in systemic hemodynamics, hepatosplanchnic circulation, and oxygen delivery were measured. Furthermore, the variable changes in the concentrations of nitrite and nitrate (NOx), anandamide, and BH4 were measured. To access the effects of surgery, anesthesia, and fluid management on BH4, an experiment without LPS infusion was performed in two other animals.ResultsMean arterial pressure and cardiac index started to decrease at 60 min after LPS infusion. However, systemic vascular resistance remained unchanged. Total hepatic blood flow and hepatic oxygen delivery also decreased significantly. NOx and anandamide did not change during LPS infusion. BH4 values did not change without LPS infusion. However, BH4 values increased significantly in the arterial, portal, and hepatic circulation during LPS infusion, especially in the hepatic vein (from 136.8 ± 27.5 to 281.3 ± 123.2 mol/ml; P < 0.01).ConclusionOur data suggest that the BH4 values were significantly increased in several organs, especially in the liver during endotoxic shock. Impaired cardiac output and decreased blood pressure appeared in the early phase of porcine endotoxemia. Longer-term observation of these parameters after LPS treatment should be performed as the next step in future studies.

Re-evaluation of the reliability of cytochrome oxidase--signal study of cardiopulmonary bypass.

The monitoring of brain oxygen status using near-infrared spectroscopy (NIRS) has recently been applied to clinical practice in the field of cardiovascular surgery. Published studies have indicated that NIRS could be used as a continuous and noninvasive way of observing changes in the cerebral oxygenation state during hypoxia and ischemia, since changes occur in optical properties under these conditions. However, the interpretation of NIRS data, especially the cytochrome oxidase (cyt. ox.) signal, remains controversial. A possible source of error that might interfere with the accurate measurement of the redox state of cyt. ox. derives from an overlapping of the absorption spectra for hemoglobin and cyt. ox. in the near-infrared region, with the absorption coefficient for hemoglobin being an order of magnitude greater than that for cyt. ox.. Recently, it was reported that the cyt. ox. signal measured by near-infrared spectroscopy (NIRS) is highly contaminated with the hemoglobin signal [1]. However, the cyt. ox. signal measured by NIRS would be expected to be strongly dependent on the algorithm employed. We have developed a new approach to the measurement of the redox state of cyt. ox. in the brain involving the use of a new algorithm [2], which has already been employed in clinical medicine [3, 4]. Therefore, in this paper we looked for evidence of cross-talk between the cytochrome and hemoglobin (Hb) signals when our new algorithm was used under cardiopulmonary bypass (CPB) in a dog model. Furthermore, we retrospectively studied the relationship between data obtained concerning the redox behavior of cyt. ox. during surgery (again using our new algorithm) and neurological prognosis in 105 patients.

Perfusion index as a possible predictor for postanesthetic shivering

BackgroundPostanesthetic shivering can be triggered by surgical stress and several aspects of anesthetic management and is frequently preceded by a decrease in peripheral blood flow due to thermoregulatory vasoconstriction. As perfusion index correlates with peripheral blood flow, we examined whether perioperative perfusion index, measured using pulse oximetry, might be correlated with postanesthetic shivering.MethodsTwenty-eight patients presenting for elective abdominal surgery were enrolled. Core (esophagus) and peripheral (finger) temperatures and perfusion index were recorded in the perioperative periods. Correlations between perfusion index and peripheral temperature and core-to-peripheral temperature gradient were then explored. Plasma levels of epinephrine and norepinephrine were also measured. The extent of shivering was graded after emergence from anesthesia.ResultsPerfusion index declined before emergence from anesthesia in patients who then developed postanesthetic shivering. This coincided with the time at which the difference between core and peripheral temperature became dissociated and peripheral temperature declined. Perioperative perfusion index was correlated with peripheral temperature and peripheral-core temperature gradient. Perfusion index at closure of the peritoneum predicted postanesthetic shivering and was significantly correlated with the extent of shivering. Plasma levels of both epinephrine and norepinephrine were significantly elevated after shivering events.ConclusionsPerfusion index was significantly lower in patients with postanesthetic shivering before emergence from anesthesia, indicating that measurement of perfusion index during and before the end of anesthesia might be a useful means of predicting postanesthetic shivering.

Management of general anesthesia in a child with Miller–Dieker syndrome: a case report

Miller–Dieker syndrome (MDS) is a rare disorder characterized by type I lissencephaly and a distinctive facial appearance that may include prominent forehead, bitemporal hollowing, and micrognathia. MDS is associated with epilepsy. We here report an 18-month-old girl with MDS who required general anesthesia. The child had an extremely low Bispectral Index (BIS) value prior to undergoing general anesthesia. Her perioperative course was uneventful. This case highlights some of the important anesthetic concerns in patients with MDS, which include potentially difficult airways and extremely low BIS values.