Taro Mizutani

Hemodynamic responses to tracheal intubation with laryngoscope versus lightwand intubating device (Trachlight®) in adults with normal airway

Lightwand devices are effective and safe as an aid to tracheal intubation. Theoretically, avoiding direct-vision laryngoscopy could allow for less stimulation by intubation than the conventional laryngoscopic procedure. We designed this prospective randomized study to assess the cardiovascular changes after either lightwand or direct laryngoscopic tracheal intubation in adult patients anesthetized with sevoflurane. Sixty healthy adult patients with normal airways were randomly assigned to one of three groups according to intubating procedure under sevoflurane/nitrous oxide anesthesia (fraction of inspired oxygen = 0.33) (n = 20 each). The lightwand group received tracheal intubation with Trachlight®, the laryngoscope-intubation group received tracheal intubation with a direct-vision laryngoscope (Macintosh blade), and the laryngoscopy-alone group received the laryngoscope alone. Heart rate and systolic blood pressure were recorded continuously for 5 min after tracheal intubation or laryngoscopy with enough time to intubate. All procedures were successful on the first attempt. The maximum heart rate and systolic blood pressure values obtained after intubation with Trachlight (114 ± 20 bpm and 143 ± 30 mm Hg, respectively) did not differ from those with the Macintosh laryngoscope (114 ± 20 bpm and 138 ± 23 mm Hg), but they were significantly larger than those in the laryngoscopy-alone group (94 ± 19 bpm and 112 ± 21 mm Hg) (P < 0.05). Direct stimulation of the trachea appears to be a major cause of the hemodynamic changes associated with tracheal intubation.

Prolonged use of dexmedetomidine in an infant with respiratory failure following living donor liver transplantation

We used dexmedetomidine for more than 2 months in a mechanically ventilated infant without serious adverse effects. An infant with liver cirrhosis of unknown cause underwent living donor liver transplantation at the age of 9 months. Long‐term mechanical ventilation was required postoperatively, and midazolam with fentanyl had been used to sedate the patient. They required increase to 1.7 mg·kg−1·h−1 and 3.5 μg·kg−1·h−1, respectively, which were still inadequate. On postoperative day 29, dexmedetomidine was added. The rate of dexmedetomidine infusion was increased gradually to 1.4 μg·kg−1·h−1. It was discontinued temporarily to exclude drug‐induced liver dysfunction. However, without dexmedetomidine, adequate sedation level was unattainable. Liver dysfunction was likely to be attributed to cytomegalovirus infection and after restarting dexmedetomidine, the respiratory condition improved. He was extubated 10 weeks after the operation. Dexmedetomidine was successfully tapered off over the following 2 weeks with no signs of withdrawal. Dexmedetomidine was a useful sedative for an infant who required mechanical ventilation for a prolonged period of time.

Association of age at menarche with metabolic syndrome and its components in rural Bangladeshi women.

BackgroundEarly age at menarche is associated with increased risk of metabolic syndrome in both China and the West. However, little is known about the impact of age at menarche and metabolic syndrome in South Asian women, including those from low-income country, where age at menarche is also falling. The aim of the present study was to investigate whether age at menarche is inversely associated with metabolic syndrome in Bangladeshi women, who are mostly poor and have limited access to and or poor health care facilities.MethodsThis community-based cross-sectional study was performed using 1423 women aged between 15–75 years from rural Bangladesh in 2009 and 2010. Metabolic syndrome was defined according to standard NCEP-ATP III criteria. Logistic regression was used to estimate the association between age at menarche and metabolic syndrome, with adjustment of potential confounding variables, including age, education, marital status, tobacco users, use of contraceptives and number of pregnancies.ResultsEarly onset of menarche (<12 years) as compared to late onset (>13 years) was found to be associated with a higher prevalence of metabolic syndrome (odds ratio=1.55; 95 % confidence interval =1.05-2.30). Age at onset of menarche was also inversely associated with prevalence of high triglycerides (P for trend <0.01) and low high-density lipoprotein cholesterol (P for trend = 0.01), but positively associated with prevalence of high fasting blood glucose (P for trend =0.02). However, no significant association was found between age at menarche, high blood pressure and elevated waist circumference.ConclusionEarly onset of menarche might promote or trigger development of metabolic syndrome. Thus, knowledge of the history of age at onset of menarche may be critical in identifying women at risk of developing metabolic syndrome and those likely to benefit the most from early interventions.

Prolonged sevoflurane inhalation therapy for status asthmaticus in an infant.

A 3‐month‐old boy with retractive breathing from his birth was scheduled for a rigid bronchoscopic examination. Anesthesia was induced and maintained with sevoflurane. The examination revealed a slight laryngomalacia which was not compatible with his severe symptom. During the procedure, no respiratory deterioration occurred. He was once extubated in the operating room, however, developed severe desaturation immediately. He was reintubated at the scene and returned to the ward being mechanically ventilated and sedated. The next day, his respiratory condition worsened gradually. Conventional drugs including theophylline, corticosteroid and beta adrenergic agonist did not improve his deleterious condition. He became bradycardic and was on the verge of circulatory collapse as his lungs were unable to ventilate. Then, we commenced inhalation of sevoflurane using a standard anesthesia machine, which relieved him from ventilatory crisis. Although there were some difficulties in using anesthesia machine in the ICU, we could successfully manage mechanical ventilation. After the beginning of sevoflurane inhalation, his condition improved gradually. Discontinuation of sevoflurane was difficult and it took 94 h to wean from sevoflurane inhalation. Despite long duration of inhalation, no adverse effects of sevoflurane were observed except transient mild increase in liver transaminase. There have been very few reports on application of sevoflurane inhalation for such a long period in infants with bronchospasm. Moreover, measured serum fluoride concentration (24.2 μmol·l−1) during inhalation was well below harmful level. Sevoflurane inhalation is worth attempting and safe to treat life‐threatening bronchospasm even in infants.

Oral clonidine premedication decreases energy expenditure in human volunteers

PurposeClonidine not only stops postoperative shivering and decreases oxygen consumption, but also decreases energy expenditure with or without a reduction in shivering during recovery from anaesthesia. It is important to see if clonidine decreases energy expenditure at rest since this may contnbute to a postoperative decrease in energy expenditure. The authors tested the hypothesis that oral clonidine decreases energy expenditure at rest.MethodsTwenty healthy male volunteers were randomly assigned to one of two groups. Ten volunteers received oral clonidine approximately 5 μg·kg−1 (clonidine group), while the remaining 10 volunteers received placebo (control group). Blood pressure, heart rate, body temperature at the tympanic membrane, sedation score graded from 1 (alert) to 5 (sleeping and difficult to be aroused by tactile stimulation) were measured before and at 30-mm intervals for three hours after administration of clonidine or placebo. Measurements of energy expenditure and respiratory quotient were made with a head canopy system at one-minute intervals and averaged over 15 mm before, and at 30, 60, 90, 120, and 180 min after administration of clonidine or placebo.ResultsSedation score increased from 1 to 3 (median) after clonidine administration. Energy expenditure decreased from 1452± 225 kcal·24hr (mean± SD) at baseline to 1258 ± 175 kcal·24hr at 180 min after clonidine administration (P < 0 05).ConclusionThis study suggests that oral clonidine at a dose of 5 μg·kg−1 decreases energy expenditure at rest.RésuméObjectifEn plus de prévenir le frisson postopératoire et de diminuer la consommation en oxygène, la clonidine diminue la dépense énergétique au moment du réveil avec ou sans atténuation du frisson. Il est important de savoir si la clonidine diminue la dépense énergétique au repos étant donné que cet effet contribue a une baisse postopératoire de l’énergie dépensée.MéthodesVingt volontaires en bonne santé de sexe masculin étaient assignés aléatoirement à deux groupes. Dix de ces volontaires recevaient environ 5 μg·kg−1 de clonidine (groupe clonidine) alors que les autres recevaient un placebo (groupe contrôle). La pression artérielle, la fréquence cardiaque, la température corporelle et tympanique, le score de sedation coté sur une échelle de I (alerte) à 5 (endormi et difficile à réveiller par stimulation tactile) étaient notés avant et à 30 min d’intervalles pendant trois heures suivant l’administration de la clonidine ou du placebo. Les mesures de la dépense énergétique et du quotient respiratoire étaient réalisées à l’aide d’un casque et leurs moyennes calculées sur une pénode de 15 min avant et 30, 60, 90, 120 et 180 min après l’administration de la clonidine ou du placebo.RésultatsLe score de sedation a augmenté de 1 à 3 (médiane) après l’administration de la clonidine. La dépense énergétique a diminué de 1452 ± 225 kcal·24h−1 (moyenne ± ET) initialement, à 1285 ± 175 kcal·24h 180 min après l’administration de la clonidine (P < 0,05).ConclusionCette étude suggère qu’au repos, la clonidine orale 5 μg·kg−1 diminue la dépense énergétique.

Rectal Ulcer with Massive Haemorrhage due to Activated Charcoal Treatment in Oral Organophosphate Poisoning

A 42-year-old woman who had ingested a large amount of fenitrothion emulsion was admitted and treated. Treatments consisted of mechanical ventilation, intravenous administration of atropine and pralidoxime and repeated injection of activated charcoal with magnesium sulphate via a nasogastric tube. The patient developed massive rectal bleeding just after she had passed several hard masses of charcoal on the 10th day. Surgical haemostasis of the rectal ulcer was needed to control the haemorrhage.

The effects of 30% and 60% xenon inhalation on pial vessel diameter and intracranial pressure in rabbits.

Xenon may increase cerebral blood flow and intracranial pressure (ICP). To evaluate the effects of xenon on brain circulation, we measured pial vessel diameter changes, CO2 reactivity, and ICP during xenon inhalation in rabbits. Minimum alveolar anesthetic concentration (MAC) for xenon was established in rabbits (n = 6). By using a cranial window model, pial vessel diameters were measured at 30% and 60% xenon inhalation and in time control groups (n = 15). ICP, mean arterial blood pressure, and heart rate were recorded during 30% and 60% xenon inhalation (n = 5). Pial vessel diameters were measured during hypocapnia and hypercapnia conditions in 60% Xenon and Control groups (n = 14). MAC for xenon was 85%. Xenon (0.35 and 0.7 MAC) dilated the arterioles (10% and 18%, respectively) and venules (2% and 4%, respectively) (P < 0.05). Dilation of arterioles was more prominent than that of venules. ICP, mean arterial blood pressure, and heart rate did not change during xenon inhalation. No difference in CO2 reactivity was observed between Xenon and Control groups (P = 0.79). Sixty percent xenon (0.7 MAC) dilated brain vessels, but venule changes were small. Xenon did not increase ICP and preserved CO2 reactivity of the brain vessels.

Efficacy of Whole Bowel Irrigation Using Solutions with or without Adsorbent in the Removal of Paraquat in Dogs

1 The efficacy of whole bowel irrigation with a solution containing either polyethylene glycol (PEG) with electrolyte or an adsorbent (Kayexalate™) with a cathartic (sorbitol) was investigated in 18 dogs who had been given 250 mg kg -1 paraquat dichloride via a jejunal tube to eliminate the influence of gastric absorption. 2 Plasma paraquat concentrations 2 and 3 h after the initiation of bowel irrigation and at the end of the study (5 h later) were significantly lower in the bowel irrigation groups than in the control (no bowel irrigation) group. 3 The total body clearances of paraquat in the bowel irrigation groups were significantly greater than in the control group. 4 There were no significant differences between the two different irrigation solution groups in plasma paraquat concentration, the area under the plasma concentration time curve and the total body clearance. 5 In the PEG with electrolyte group, about 70% of the administered dose of paraquat was removed by means of bowel irrigation (n=4). 6 The adjunction of the adsorbent had no beneficial effects. 7 Haemodynamic changes associated with whole bowel irrigation were unremarkable except that right atrial and pulmonary arterial pressures were elevated in the latter part of the study.

Do dispatcher instructions facilitate bystander-initiated cardiopulmonary resuscitation and improve outcomes in patients with out-of-hospital cardiac arrest? A comparison of family and non-family bystanders

OBJECTIVES Bystander-initiated cardiopulmonary resuscitation (CPR) has been reported to increase the possibility of survival in patients with out-of-hospital cardiopulmonary arrest (OHCA). We evaluated the effects of CPR instructions by emergency medical dispatchers on the frequency of bystander CPR and outcomes, and whether these effects differed between family and non-family bystanders. METHODS We conducted a retrospective cohort study, using Utstein-style records of OHCA taken in a rural area of Japan between January 2004 and December 2009. RESULTS Of the 559 patients with non-traumatic OHCA witnessed by laypeople, 231 (41.3%) were given bystander CPR. More OHCA patients received resuscitation when the OHCA was witnessed by non-family bystanders than when it was witnessed by family members (61.4% vs. 34.2%). The patients with non-family-witnessed OHCA were more likely to be given conventional CPR (chest compression plus rescue breathing) or defibrillation with an AED than were those with family-witnessed OHCA. Dispatcher instructions significantly increased the provision of bystander CPR regardless of who the witnesses were. Neurologically favorable survival was increased by CPR in non-family-witnessed, but not in family-witnessed, OHCA patients. No difference in survival rate was observed between the cases provided with dispatcher instructions and those not provided with the instructions. CONCLUSIONS Dispatcher instructions increased the frequency of bystander CPR, but did not improve the rate of neurologically favorable survival in patients with witnessed OHCA. Efforts to enhance the frequency and quality of resuscitation, especially by family members, are required for dispatcher-assisted CPR.

Screening for gestational diabetes mellitus and its prevalence in Bangladesh

BACKGROUND The prevalence of gestational diabetes mellitus (GDM) has important health complications for both mother and child and is increasing all over the world. Although prevalence estimates for GDM are not new in developed and many developing countries, data are lacking for many low-income countries like Bangladesh. OBJECTIVE To evaluate the prevalence of GDM in Bangladesh. RESEARCH DESIGN AND METHODS This cross-sectional study included 3447 women who consecutively visited the antenatal clinics with an average gestation age of 26 weeks. GDM was defined according to WHO criteria (fasting plasma glucose [FPG] ≥7.0 mmol/L or 2-h ≥7.8 mmol/L) and the new ADA criteria (FPG ≥5.3 mmol/L or 2-h ≥8.6 mmol/L OGTT). We also calculated overt diabetes as FPG ≥7.0 mmol/L. RESULTS Prevalence of GDM was 9.7% according to the WHO criteria and 12.9% according to the ADA criteria in this study population. Prevalence of overt diabetes was 1.8%. Women with GDM were older, higher educated, had higher household income, higher parity, parental history of diabetes, and more hypertensive, compared with non-GDM women. CONCLUSION This study demonstrates a high prevalence of GDM in Bangladesh. These estimates for GDM may help to formulate new policies to prevent and manage diabetes.