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The present study aimed to evaluate the effect of electrosurgical devices on neuromuscular monitoring using an electromyography (EMG)-based neuromuscular monitor during abdominal laparotomy. Seventeen women (aged 32-64 years) undergoing gynecological laparotomy under total intravenous general anesthesia were enrolled in the study. A TetraGraph™ was placed to stimulate the ulnar nerve and to monitor the abductor digiti minimi muscle. After device calibration, train-of-four (TOF) measurements were repeated at intervals of 20 s. Rocuronium 0.6 to 0.9 mg/kg was administered for induction, and additional doses of 0.1 to 0.2 mg/kg were administered to maintain TOF counts ≤ 2 during the surgery. The primary outcome of the study was the ratio of measurement failure. The secondary outcomes of the study were the total number of measurements, the number of measurement failures, and the most extended consecutive number of measurement failures. The data are expressed as median (range). Of the 3091 (1480-8134) measurements, the number of measurement failures was 94 (60-200), resulting in a failure ratio of 3.5% (1.4-6.5%). The most extended consecutive number of measurement failures was 8 (4-13). All attending anesthesiologists were able to maintain and reverse neuromuscular blocks under EMG guidance. This prospective observational study demonstrated that the use of EMG-based neuromuscular monitoring does not seem to be heavily affected by electrical interference during lower abdominal laparotomic surgery. Trial registration This trial was registered in the University Hospital Medical Information Network under registration number UMIN000048138 (registration date; June 23, 2022)., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: We compared the reversal doses of sugammadex in surgical cases in which intraoperative neuromuscular monitor were used, to cases in which intraoperative neuromuscular monitoring was not used, retrospectively., Methods: Data were collected by reviewing the electronic medical records of patients who received rocuronium and sugammadex during general anesthesia at Asahikawa Medical University Hospital between May 1, 2017 and April 30, 2018. The primary outcome was the reversal dose of sugammadex per patient actual body weight (mg/kg) between the group in which intraoperative neuromuscular monitoring was used (NM+ group) and the group in which intraoperative neuromuscular monitoring was not used (NM- group)., Results: A total of 3496 patients were evaluated, with 2544 patients (73%) included in NM+ group and 952 patients (27%) in NM- group. The reversal doses of sugammadex per actual body weight were significantly higher in NM- group compared to NM+ group. In the NM+ group, 521 patients (20%) received < 2 mg/kg sugammadex, 1377 patients (54%) received 2 ~ 2.5 mg/kg sugammadex, and 646 patients (25%) received > 2.5 mg/kg sugammadex. In contrast, 128 patients (13%) received < 2 mg/kg sugammadex, 362 patients (38%) received 2 ~ 2.5 mg/kg sugammadex and 462 patients (49%) received > 2.5 mg/kg sugammadex in NM- group., Conclusion: This single-center retrospective study demonstrated that the use of intraoperative neuromuscular monitor reduced the reversal dose of sugammadex.

Background and Objectives: Although high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact of HSA technique on fast-track strategy in cardiac surgery., Methods: Elective cardiac surgery cases (n=1025) were divided into two groups: cases with HSA combined with general anesthesia (GA) (HSA group, n=188) and cases with GA only (GA group, n=837). In the HSA group, bupivacaine and morphine were intrathecally administered immediately before GA was induced. Outcomes included fast-track extubation (less than 6 hours), extubation in the operating room, fast-track discharge from the intensive care unit (ICU) (less than 48 hours) and hospital (less than 7 days)., Results: In the HSA group, 60.1% were extubated in less than 6 hours after ICU admission, as compared with 39.9% in the GA group (p<0.001). In the HSA group, 33.0% were extubated in the operating room, as compared with 4.4% in the GA group (p<0.001). LOS in the ICU was less than 48 hours in 67.6% in the HSA group, as compared with 57.2% of those in the GA group (p=0.033). LOS in the hospital was less than 7 days in 63.3% in the HSA group, as compared with 53.5% in the GA group (p=0.084)., Conclusions: HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Surgical revascularisation to accomplish limb salvage remains preferable in some patients with chronic limb threatening ischaemia (CLTI). The aim of this study was to evaluate the effectiveness and safety of ultrasound guided lower extremity nerve blockade (UGNB) in infragenicular bypass surgery (IGBS)., Methods: This was a single centre, retrospective clinical study. Fifty-nine patients with CLTI (67 limbs) who underwent IGBS under UGNB (femoral and sciatic nerve blockade) at Asahikawa Medical University between January 2012 and December 2017 were compared with patients with CLTI (137 limbs) who underwent IGBS under general anaesthesia (GA) over the same period. Propensity score matching based on pre-operative comorbidities was used to minimise background differences of the two groups., Results: Fifty-six pairs of CLTIs were matched and analysed (55% dialysis dependent). Procedure duration was similar between the two groups, but intraoperative catecholamine index and intravenous fluid volume were lower with UGNB compared with GA (2.9 ± 4.6 vs. 5.9 ± 6.5; p < .01 and 1831 ± 990 vs. 2335 ± 931 mL; p < .01, respectively). The mean arterial blood pressure during induction of anaesthesia was significantly decreased with GA. Post-operatively, the time period to resume a clear liquid and solid food diet was significantly shorter with UGNB (P<0.01 for both outcome measures). Intravenous fluid volume was significanlty lower, while cardiac complications and delirium, based on the NEECHAM confusion scale, occurred significantly less often with UGNB than GA. These significant differences show advantages of UGNB compared to GA. No mortality or major amputations were observed in either group. Early graft thrombosis was observed in five limbs (8.9%) with UGNB and in four limbs with GA (7.1%) (p = .73)., Conclusions: UGNB has advantages for intra- and post-operative management and could be a useful method to prevent peri-operative complications for high risk patients with CLTI. To ensure the effectiveness of UGNB for IGBS for future indications, a randomised study is required., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Although the world understands the possible threat of the future of climate changes, there remain serious barriers to be resolved in terms of policy decisions. The scientific and the societal uncertainties in the climate change policies must be the large part of this barrier. Following the Paris Agreement, the world comes to the next stage to decide the next actions. Without a view of risk management, any decision will be "based on neglecting alternatives" behavior. The Ministry of the Environment, Japan has established an inter-disciplinary research project, called Integrated Climate Assessment-Risks, Uncertainties, and Society (ICA-RUS) conducted by Dr. Seita Emori, National Institute for Environmental Studies. ICA-RUS consists of five research themes, i.e., (1) synthesis of global climate risks, (2) optimization of land, water, and ecosystem for climate risks, (3) analysis of critical climate risks, (4) evaluation of climate risk management options, and (5) interactions between scientific and social rationalities. We participated in the fourth theme to provide the quantitative assessment of technology options and policy measures by integrating assessment model simulations. We employ the multi-model approach to deal with the complex relationships among various fields such as technology, economics, and land use changes. Four different types of integrated assessment models, i.e., MARIA-14 (Mori), EMEDA (Washida), GRAPE (Kurosawa), and AIM (Masui), participate in the fourth research theme. These models contribute to the ICA-RUS by providing two information categories. First, these models provide common simulation results based on shared socioeconomic pathway scenarios and the shared climate policy cases given by the first theme of ICA-RUS to see the ranges of the evaluation. Second, each model also provides model-specific outcomes to answer special topics, e.g., geoengineering, sectoral trade, adaptation, and decision making under uncertainties. The purpose of this paper is to describe the outline and the main outcomes of the multi-model inter-comparison among the four models with a focus upon the first and to present the main outcomes. Furthermore, in this study, we introduce a statistical meta-analysis of the multi-model simulation results to see whether the differently structured models provide the inter-consistent findings. The major findings of our activities are as follows: First, in the stringent climate target, the regional economic losses among models tend to diverge, whereas global total economic loss does not. Second, both carbon capture and storage (CCS) as well as BECCS are essential for providing the feasibility of stringent climate targets even if the deployment potential varies among models. Third, the models show small changes in the crop production in world total, whereas large differences appear between regions. Fourth, the statistical meta-analysis of the multi-model simulation results suggests that the models would have an implicit but common relationship between gross domestic product losses and mitigation options even if their structures and simulation results are different. Since this study is no more than a preliminary exercise of the statistical meta-analysis, it is expected that more sophisticated methods such as data mining or machine learning could be applicable to the simulation database to extract the implicit information behind the models.

Several analytical methods for dexmedetomidine (DEX) in human plasma have been published, but quantification of DEX in human breast milk has not been described. In this article, we describe a high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method suitable for quantification of DEX in human breast milk. DEX and an internal standard were extracted in a single liquid-liquid extraction step with diethyl ether from 200μL of human breast milk. HPLC was performed on a TSK-gel ODS-100V column with isocratic elution at a flow rate of 0.3mL/min using a mobile phase of 5mM ammonium formate:0.1% formic acid in acetonitrile (60:40, v/v). Detection was performed using an API4000 mass spectrometer with positive electrospray ionization. The method was validated in the concentration range of 10pg/mL (lower limit of quantification) to 2000pg/mL. The intra- and inter-day accuracy were within ±5.8% and precision was <6.31% based on the coefficient of variation. The recoveries of DEX in human breast milk were 82.4-87.9%. Recovery and matrix effects were consistent and reproducible for human breast milk. The method is robust and was successfully used in a study of drug safety in breastfeeding in patients after administration of DEX., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Study Objective: Hypertension or hypotension in patients receiving continuous infusions of dexmedetomidine (DEX) is often due to changes in vascular resistance caused by α2 receptor stimulation. We investigated whether baseline perfusion index (PI) and pleth variability index (PVI), derived from pulse oximetry readings, could predict DEX-induced changes in the hemodynamic status in spontaneously breathing patients., Design: Observational study., Setting: Operating room., Patients: Patients (American Society of Anesthesiologists performance status 1 or 2) scheduled to undergo lower extremity or abdominal procedures under regional anesthesia were approached., Interventions: The PI and PVI were set as baseline upon arrival in theater and were then measured at 2.5-minute intervals. Upon attaining stable hemodynamic status under spontaneous breathing, intravenous administration of DEX was initiated at 6 μg kg(-1) h(-1) for 10minutes, followed by continuous infusion at 0.6 μg kg(-1) h(-1)., Measurements: Blood pressure, heart rate, PI, and PVI were measured. Hypertension was defined as an increase in systolic blood pressure (SBP) >15% and hypotension as a decrease in SBP <15% from baseline., Main Results: Baseline PI and PVI correlated with the degree of change in SBP. The maximum percentage increase as well as the maximum percentage of decrease in SBP from baseline correlated with baseline PI (r=0.418 [P=.005] and r=0.507 [P<.001], respectively) and PVI (r=-0.658 [P<.001] and r=-0.438 [P=.003], respectively). PVI <15 identified DEX-induced hypertension (sensitivity 94%, specificity 85%) and PVI >16 identified DEX-induced hypotension (sensitivity 83%, specificity 64%)., Conclusions: PVI may predict DEX-induced changes in blood pressure in spontaneously breathing patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The goal of this study was to evaluate in patients with peripheral arterial disease (PAD) whether ultrasound-guided radial artery catheterization decreased procedural time and number of attempts compared with the traditional palpation technique., Methods: Ultrasonography was evaluated for arte- rial catheterization after the traditional palpation tech- nique was unsuccessful in 480 seconds in 10 patients with PAD. The vascular access was performed by a single anesthesiologist. The successful catheterization time and the number of attempts were recorded. We also measured the diameter of the radial artery, the skin-to-artery distance, and the distance between the linear probe and puncture site., Results: The mean overall time per patient for catheter insertion was 220.0?112.6 sec in the ultra- sound group vs. 480 sec in the palpation group (P= 0.0029). The mean number of attempts was 1.30?0.48 in the ultrasound group vs. 4.50?0.53 in the palpation group (P = 0.0024). All catheterizations were success- ful, and no failure was encountered in the ultrasound group., Conclusions: Ultrasound-guided radial artery cath- eterization took less time to establish the arterial line, and it reduced the number of attempts when com- pared with the palpation technique.

Background: The aim of this study was to investigate whether changes in perfusion index (PI) correlate with non-invasive haemodynamic parameters (HR, BP) following the onset of pneumoperitoneum under two doses (moderate-dose (MD) and high-dose (HD)) of remifentanil and to compare its reliability., Methods: We divided 33 patients who were scheduled for laparoscopic surgery under general anesthesia into two groups according to the dose of continuously infused remifentanil: moderate dose 0.5 μg x kg(-1) x min(1) (MD group, n = 16) and high dose 1.0 μg x kg(-1) x min(-1) (HD group, n = 17). Non-invasive blood pressure (NIBP), HR, and PI were measured before the start of surgery (time 1), after the start of surgery (time 2), before the start of pneumoperitoneum (time 3), and 1 min after the stable state of pneumoperitoneum (time 4)., Results: PI decreased from the baseline after pneumoperitoneum in MD group, on the other hand PI did not change in HD group. Between the two groups, the magnitude of the PI changes was statistically different although MBP and HR were not statistically different, Conclusions: PI may be a reliable and easier alternative to conventional haemodynamic parameters for detection of stress response to pneumoperitoneum during remifentanil anaesthesia in adult patients.

Purpose: We previously determined the pharmacokinetic (PK) parameters of landiolol in healthy male volunteers. In this study, we evaluated the usefulness of target-controlled infusion (TCI) of landiolol hydrochloride and determined PK parameters of landiolol in gynecologic patients., Methods: Nine patients who were scheduled to undergo gynecologic surgery were enrolled. After inducing anesthesia, landiolol hydrochloride was administered at the target plasma concentrations of 500 and 1,000 ng/mL for each 30 min. A total of 126 data points of plasma concentration were collected from the patients and used for the population PK analysis. Furthermore, a population PK model was developed using the nonlinear mixed-effect modeling software., Results: The patients had markedly decreased heart rates (HRs) at 2 min after the initiation of landiolol hydrochloride administration; however, their blood pressures did not markedly change from the baseline value. The concentration time course of landiolol was best described by a 2-compartment model with lag time. The estimate of PK parameters were total body clearance (CL) 34.0 mL/min/kg, distribution volume of the central compartment (V 1) 74.9 mL/kg, inter-compartmental clearance (Q) 70.9 mL/min/kg, distribution volume of the peripheral compartment (V 2) 38.9 mL/kg, and lag time (ALAG) 0.634 min. The predictive performance of this model was better than that of the previous model., Conclusion: TCI of landiolol hydrochloride is useful for controlling HR, and the PK parameters of landiolol in gynecologic patients were similar to those in healthy male volunteers and best described by a 2-compartment model with lag time.

Purpose: We previously determined the pharmacokinetic (PK) parameters of landiolol in healthy male volunteers and gynecological patients. In this study, we determined the PK parameters of landiolol in patients with peripheral arterial disease., Methods: Eight patients scheduled to undergo peripheral arterial surgery were enrolled in the study. After inducing anesthesia, landiolol hydrochloride was administered at target plasma concentrations of 500 and 1,000 ng/mL for 30 minutes each. A total of 112 data points of plasma concentration were collected from the patients and used for the population PK analysis. A population PK model was developed using a nonlinear mixed-effect modeling software program (NONMEM)., Results: The patients had markedly decreased heart rates at 2 minutes after initiation of landiolol hydrochloride administration; however, systolic blood pressures were lower than the baseline values at only five time points. The concentration time course of landiolol was best described by a two-compartment model with lag time. The estimates of PK parameters were as follows: total body clearance, 30.7 mL/min/kg; distribution volume of the central compartment, 65.0 mL/kg; intercompartmental clearance, 48.3 mL/min/kg; distribution volume of the peripheral compartment, 54.4 mL/kg; and lag time, 0.633 minutes. The predictive performance of this model was better than that of the previous model., Conclusion: The PK parameters of landiolol were best described by a two-compartment model with lag time. Distribution volume of the central compartment and total body clearance of landiolol in patients with peripheral arterial disease were approximately 64% and 84% of those in healthy volunteers, respectively.

Purpose: The general dexmedetomidine (DEX) concentration required for sedation of intensive care unit patients is considered to be approximately 0.7 ng/mL. However, higher DEX concentrations are considered to be required for sedation and/or pain management after major surgery using remifentanil. We determined the DEX concentration required after major surgery by using a target-controlled infusion (TCI) system for DEX., Methods: Fourteen patients undergoing surgery for abdominal aortic aneurysms (AAA) were randomly, double-blindly assigned to two groups and underwent fentanyl- or remifentanil-based anesthetic management. DEX TCI was started at the time of closing the peritoneum and continued for 12 hours after stopping propofol administration (M0); DEX TCI was adjusted according to the sedation score and complaints of pain. The doses and concentrations of all anesthetics and postoperative conditions were investigated., Results: Throughout the observation period, the predicted plasma concentration of DEX in the fentanyl group was stable at approximately 0.7 ng/mL. In contrast, the predicted plasma concentration of DEX in the remifentanil group rapidly increased and stabilized at approximately 2 ng/mL. The actual DEX concentration at 540 minutes after M0 showed a similar trend (0.54±0.14 [fentanyl] versus 1.57±0.39 ng/mL [remifentanil]). In the remifentanil group, the dopamine dose required and the duration of intubation decreased, and urine output increased; however, no other outcomes improved., Conclusion: The DEX concentration required after AAA surgery with remifentanil was three-fold higher than that required after AAA surgery with fentanyl or the conventional DEX concentration for sedation. High DEX concentration after remifentanil affords some benefits in anesthetic management.

We report three cases with systolic anterior motion (SAM) after mitral valve plasty. Preoperative mitral valve morphology is a risk factor for SAM. The morphological characteristics of SAM have been revealed in several studies. We found a small distance between coaptation and the interventricular septum in all cases, and cases 2, and 3 had a low AL/PL ratio, whereas case 3 had a large PML, which was revealed by transesophageal echocardiography. With the use of 3D transesophageal echocardiography, when mitral valve prolapse was investigated, in all three cases, it was easy to specify lesions. The issue for the future is 3D analysis when SAM is occurring.

Background: Olprinone decreases the cardiac preload and/or afterload because of its vasodilatory effect and increases myocardial contractility by inhibiting phosphodiesterase III., Purpose: The objective of this study was to characterize the population pharmacokinetics of olprinone after a single continuous infusion in healthy male volunteers., Methods: We used 500 plasma concentration data points collected from nine healthy male volunteers for the study. The population pharmacokinetic analysis was performed using the nonlinear mixed effect model (NONMEM®) software., Results: The time course of plasma concentration of olprinone was best described using a two-compartment model. The final pharmacokinetic parameters were total clearance (7.37 mL/minute/kg), distribution volume of the central compartment (134 mL/kg), intercompartmental clearance (7.75 mL/minute/kg), and distribution volume of the peripheral compartment (275 mL/kg). The interindividual variability in the total clearance was 12.4%, and the residual error variability (exponential and additive) were 22.2% and 0.129 (standard deviation). The final pharmacokinetic model was assessed using a bootstrap method and visual predictive check., Conclusion: We developed a population pharmacokinetic model of olprinone in healthy male adults. The bootstrap method and visual predictive check showed that this model was appropriate. Our results might be used to develop the population pharmacokinetic model in patients.

We report a case of 30-second cardiac arrest that occurred during carotid body tumor resection due to the carotid sinus reflex. The patient was a 20-year-old man diagnosed with a carotid body tumor and scheduled for tumor resection. General anesthesia was induced and maintained with target controlled infusion of propofol. Analgesia was achieved with continuous administration of remifentanil. When the surgery was initiated, 1% lidocaine 3 ml was locally injected into the carotid bifurcation. When surgery was initiated in the neck region, the patient developed sudden cardiac arrest. Chest compression was immediately initiated, and atropine 0.5 mg was administered; subsequently circulation was restored. Surgery was resumed after placing a temporary pacemaker through the left subclavian vein. The surgery was successfully performed without any other bradycardia complications, and the patient recovered from general anesthesia without sequelae. Thus, the findings indicate the importance of considering the pacemaker placement before carotid body tumor resection.

76-year-old man was diagnosed with DeBakey type IIIb acute aortic dissection, for which he underwent axillo-femoral bypass surgery. Two days postoperatively, hematochezia developed suddenly. Laboratory data revealed AST 5,088 IU x l(-1), ALT 3,822 IU x l(-1), and CK 27,746 IU x l(-1) suggesting intestinal malperfusion due to stenosis of the celiac artery (CEA) and superior mesenteric artery (SMA). The abdominal aorta and visceral arteries were evaluated by transesophageal echocardiography (TEE). Color Doppler imaging revealed increased blood flow velocity (4.0 m x sec(-1)) in CEA due to the stenosis, while that in SMA was decreased. Open abdominal aortic fenestration was performed. The aorta was clamped at the level of the infra-renal and inferior mesenteric arteries, and the septum between the false and true lumens was resected. On postoperative TEE assessment, CEA stenosis was resolved, and flow velocity was improved (3.0 m x sec(-1)). Color Doppler imaging demonstrated that fenestration resulted in recovery of SMA perfusion. Aortic fenestration is useful in the treatment of ischemic complications of aortic dissection. Its advantages include minimal invasiveness and short operative time. Bypass surgery and reoperation were avoided by evaluating visceral arteries by TEE in the case reported here.

Background: Ultrasound guided neuraxial block or central venous puncture is now becoming popular in our anesthesia practice to reduce the risk of complications. Pneumothorax is a rare, but possible complication related to these interventions even if the ultrasound is used. However, the pneumothorax itself can also be diagnosed by the ultrasound. We therefore examined the efficacy of ultrasound for diagnosing pneumothorax during lung surgery requiring one lung ventilation., Methods: In 20 elective surgery patients, transthoracic lung ultrasonography was performed. The lung sliding, comet-tail artifact, M-mode, lung pulse, and power sliding were used to eliminate pneumothorax, and the reverberation artifact was used as a sign of the pneumothorax. Ultrasound procedure was videotaped for postprocedure analysis. Both sensitivity and specificity were calculated in each case., Results: Lung sliding and M-mode procedure showed high sensitivity and specificity in diagnosing pneumothorax. Reverberation artifact also showed high sensitivity, but its specificity was too low to determine pneumothorax., Conclusions: Among six ultrasonic lung findings, lung sliding and M-mode procedure are most useful as screening methods of differentiating a pneumothorax.

To evaluate the usefulness of multiple-locus variable-number tandem-repeats analysis (MLVA) as a tool for the epidemiological analysis of bovine Salmonellosis, Salmonella enterica serotype Typhimurium and serotype 4,5,12:i:- isolates (544 and 18, respectively) obtained from cattle in Hokkaido, Japan, between 1977 and 2009, were characterised by MLVA. MLVA identified 184 profiles versus 121 profiles identified by pulsed-field gel electrophoresis (PFGE). Cluster analysis of the MLVA profiles demonstrated 3 major clusters (A, B, and C) and 3 minor clusters (D, E, and F). Cluster A was associated with PFGE cluster I, which included isolates of definitive phage type 104 (DT104), while cluster C was associated with PFGE cluster VII, which has been disseminating among cattle since 2002. An isolate of serotype Typhimurium belonging to MLVA cluster F, in which 10 serotype 4,5,12:i:- isolates were included, was found to have an MLVA profile closely related to those of serotype 4,5,12:i:- isolates, suggesting that such a strain may be an ancestral candidate for serotype 4,5,12:i:-. Overall, the discriminatory power of MLVA was higher than that of PFGE, and MLVA differentiated between the isolates of the DT104 family, which appeared to be clonal by PFGE. However, this depended on PFGE clusters because PFGE allowed greater discrimination between isolates within PFGE cluster IV and VI than MLVA. The combination of PFGE and MLVA data allowed for improved subtype discrimination and enabled the identification of recently disseminated clones. Hence, MLVA can be used in combination with PFGE to effectively accelerate the molecular epidemiologic investigation of Salmonella., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Dexmedetomidine (DEX) for sedation in diagnostic and interventional cardiac catheterization (DICC) has been reported to require other drugs or rescue drugs because of its insufficient sedative effect when used alone. We administered DEX and adjusted its dose according to the bispectral index (BIS) monitor™ for DICC in a toddler; consequently, a high dose of DEX had to be administered. The patient was a 1-year and 4-month-old boy who was scheduled to undergo DICC after intracardiac repair. We used DEX alone as the sedative because this was expected to avoid oxygen supply and mechanical ventilation and to produce a safe situation for procedures around the neck. DEX was administered at the dose of 1-15 μg/kg/h according to BIS monitor™; administration of cardiovascular drugs or oxygen supply or assist ventilation, except chin lift, were not needed. The maximum predicted plasma concentration (pCp) of DEX and mean pCp were calculated as 6.1 and 4.1 ng/mL, respectively. A high dose of DEX may be required for DICC sedation, as for MRI sedation, in many cases. Although further studies should be conducted to reveal the merits and demerits of DEX in cardiac catheterization, a high dose of DEX may be useful in some cases.

Purpose: We previously confirmed the effectiveness of dexmedetomidine (DEX) for stabilizing hemodynamics as well as sparing anesthetics during anesthetic induction in patients undergoing cardiac surgery (Kunisawa et al. in J Clin Anesth 21:194-199, 1). In this study, we investigated whether these effects of DEX continue until the start of cardiopulmonary bypass (CPB)., Methods: Twenty-two patients with mild to moderate cardiovascular disease were randomized into two groups [DF2 group: DEX dose of 0.7 μg/kg/h after initial dose and effect-site concentration (ESC) of fentanyl of 2 ng/ml; PF4 group: saline and ESC of fentanyl of 4 ng/ml]. Propofol was administered for anesthetic induction and maintenance. Hemodynamics, cardiovascular drugs, ESC of propofol, and cardiovascular responses to skin incision (SI) and sternotomy (St) were measured or calculated., Results: Blood pressure (BP) at the pre-/post-SI periods was higher in the DEX group (137 ± 17/140 ± 16 mmHg) than in the placebo group (85 ± 9/109 ± 24 mmHg). Percent increases in cardiovascular response to SI or St were lower in the DEX group than in the placebo group (for example, 1.9 ± 2.2 vs. 27.4 ± 19.9% in systolic BP due to SI). ESCs of propofol at SI and St in the DEX group were lower than those in the placebo group., Conclusions: DEX combined with 2 ng/ml fentanyl before CPB can suppress the decrease in blood pressure at the pre- and post-SI periods, can blunt the cardiovascular responses to SI and St, and can spare the required ESC of propofol despite fentanyl concentration, which was half of that in the placebo group.

Background: It is difficult to achieve good postoperative analgesia in patients who undergo abdominal aortic surgery without epidural analgesia and who have a bleeding tendency or are undergoing anticoagulation therapy. Intravenous fentanyl analgesia can be used in such patients, but it occasionally causes respiratory depression. Dexmedetomidine is used to achieve postoperative sedation and analgesia without respiratory depression. We compared the methods used to achieve postoperative analgesia after abdominal aortic surgery., Methods: In the intravenous fentanyl analgesia group (group F, n = 15), 0.5 microg x kg(-1) x hr(-1) fentanyl infusion was initiated during operation and continued to the next morning. In the intravenous dexmedetomidine group (group D, n = 15), 0.4-0.7 microg x kg(-1) x hr(-1) dexmedetomidine infusion was commenced during the operation and decreased to 0.2-0.7 microg x kg(-1) x hr- in the next morning. In the control group (group C, n = 15), continuous intravenous analgesia was not used. The frequency of analgesic use, Ramsay score, PaCO2 value, and rate of nausea and shivering were evaluated on the next morning., Results: The frequency of analgesic use and Ramsay score were similar in groups F and D. The Paco2 value was higher in group F than group D., Conclusions: With regard to respiratory depression, intravenous dexmedetomidine analgesia is safer and more useful than intravenous fentanyl analgesia.

We report the clinical management of 2 adults with mental retardation because of trisomy 21 who were sedated with high-dose dexmedetomidine (DEX) alone during diagnostic cardiac catheterization (DCC). The first patient was a 25-year-old man with aortic regurgitation and ventricular septal defect. DEX increased his Ramsay sedation score; however, a high dose and bolus injection of DEX were required to perform an invasive procedure. Cardiovascular drugs were not administered and heart rate was maintained in the low 40s. The maximum predicted plasma concentration (pCp) of DEX was 2.3 ng/mL. The second patient was a 26-year-old woman who had developed hypoxia 20 years after palliative surgery for tetralogy of Fallot. High-dose DEX was administered to keep the bispectral index value below 70 and maintain an immobile state; her maximum pCp of DEX was 4.3 ng/mL. Percutaneous oxygen saturation was kept above 83%, because of the suspicion that DEX may increase the ratio of pulmonary artery flow to systemic artery flow. In both cases, no respiratory system complications occurred despite inspiration of room air, indicating the usefulness of DEX for DCC. However, because of DEX may affect DCC data, it is necessary to pay careful attention to the use of DEX during DCC.

A 69-year-old man with normal renal function underwent resection of a parotid tumor under general anesthesia. For tracheal intubation, rocuronium 0.6 mg x kg(-1) was administered, and for facial nerve stimulation, sugammadex 2 mg x kg(-1) was administered immediately after intubation. The operation time was 3 h. At the end of the surgery, sugammadex 2 mg x kg(-1) was administered again. Bleeding occurred 6 h after the surgery. During the second operation, rocuronium 0.6 mg x kg (-1) was administered for tracheal intubation. Maximal suppression was achieved 1 min 42 s after the administration of rocuronium, and the recovery time was 44 min. The times for both maximal suppression and recovery are similar to those when the same dose of rocuronium was used without sugammadex. The half-life of sugammadex is about 2 h. From the observations in this case, we think that after the completion of approximately 3 half-lives, a normal dose of rocuronium can produce the desired effect without the influence of residual sugammadex present in the plasma.

Background: Recently, rigid indirect laryngoscopes with integrated tube guidance such as Pentax-AWS (AWS) and Airtraq (ATQ) are clinically available. They are known to improve the laryngeal view and facilitate intubation compared to the Macintosh laryngoscope (MAC). However, whether these new devices are easy to learn for novice laryngoscopists is not well understood. We surveyed medical students regarding their usefulness in intubation procedure on mannequin., Methods: Sixty-six medical students with no intubation experience were enrolled. A short instruction including practice for four devices (MAC, Miller laryngoscope (MIL), AWS, and ATQ) was given. Four intubation procedures (one for each device) to the mannequin (Laerdal airway trainer) were performed. The time to place the tube, percentage of glottic opening (POGO), incidence of esophageal intubation and teeth click were recorded. Participants were asked to choose the best device for their use. For statistical analyses, ANOVA and Chi-square tests were used where appropriate, and P < 0.01 considered significant., Results: Time for intubation was significantly longer in ATQ (P < 0.01). POGO was significantly higher in AWS, but lower in MAC (P < 0.01). Complications were fewer in AWS (P < 0.01), and 70% of the participants chose AWS as the best device., Conclusion: With minimal instruction including practice, the AWS seemed to achieve safer intubation with better laryngeal view for novice laryngoscopists.

We safely administered dexmedetomidine (DEX) for sedation during spinal anesthesia in a very elderly patient. The patient was a 98-year-old woman who had hypertension, renal failure, and first-grade atrioventricular block. She was scheduled to undergo internal fixation for fracture of the femoral neck. Initially, DEX (6.0 μg/kg/h) was administered over 10 min, followed by continuous infusion at a dose of 0.7 μg/kg/h. Consequently, her Ramsay sedation score (RSS) increased to 5, and the patient did not grimace in pain while being turned to the lateral position. Epidural catheterization and spinal anesthesia were performed under sedation without any problem. The DEX dose was adjusted to maintain the RSS within 3-4. The surgical operation was performed smoothly without any problem. Since the hemodynamic condition was stable, administration of ephedrine (5 mg) was required only once during surgery. Percutaneous oxygen saturation was maintained at 98% or more; respiratory rate was within 15-21 tpm, and no ventilatory assistance was required. The maximum predicted plasma concentration (pCp) of DEX was 1.56 ng/mL, and the mean pCp of DEX during surgery was approximately 0.45 ng/mL. We found that DEX can be safely used for sedation during spinal anesthesia in a very elderly patient.

Background: We studied the effect of the initial loading dose of dexmedetomidine on hemodynamics in pediatric patient undergoing cardiac surgery., Methods: This study was on 10 children under ten who were scheduled for elective surgery for repair of the atrial and ventricular septal defect. The induction and maintenance of anesthesia were performed with total intravenous anesthesia (TIVA) using propofol and fentanyl. After closing the sternum, we administered dexmedetomidine as a loading dose of 1 microg x kg(-1) for 10 minutes followed by a maintenance infusion of 0.7 microg x kg(-) x hr(-1). During the study systolic blood pressure, diastolic blood pressure, heart rate, and central venous pressure were measured., Results: There were no significant changes temporalily in heart rate and central venous pressure. Systolic and diastolic blood pressure increased temporalily. They reached the maximum 15 minutes after starting dexmedetomidine. And 30 minutes later they returned to the baseline level., Conclusions: Any clinical problems leading to a major increase in blood pressure were not encountered. But these results suggest that it is necessary to devise a method of administration of dexmedetomidine in consideration of the patient's condition and the drug effect in severe cases.

Background: Stroke volume variation (SVV) has been shown to be a reliable predictor of fluid responsiveness. It has been reported that SVV is useful for perioperative fluid management. We evaluated SVV and hemodynamics after aortic declamping during abdominal aortic surgery., Methods: Patients scheduled to undergo abdominal aortic surgery were selected for this study. A FloTrac sensor was fitted to a 20 G cannula indwelled in the radial artery, and cardiac output (CO), central venous pressure (CVP) and SVV were continuously monitored. Patients were divided into two groups depending on pressure decrease after aortic declamping: above 50 mmHg (F group) and below 50 mmHg (N group). CO, CVP and SVV before and after the aortic declamping in the two groups were compared., Results: Thirty patients were included in this study (15 in the F group and 15 in the N group). Measurement points were 26 points in the F group and 28 points in the N group. SVV before aortic declamping in the F group was significantly higher than that in the N group. Rate of decrease in CO after aortic declamping in the F group was significantly higher than that in the N group. There was no difference in CVP between the two groups., Conclusions: The results of this study suggest that monitoring SVV during abdominal aortic surgery is useful.

Background: An anesthetic-sparing effect of dexmedetomidine has been shown in several studies. We investigated the effect of dexmedetomidine on anesthetic requirements in 24 patients undergoing cardiovascular surgery., Methods: Patients were randomly divided into two groups in which continuous infusion of dexmedetomidine was started before induction of anesthesia (DEX group, n = 12) or when closing the sternum (control group, n = 12). Dexmedetomidine was administered intravenously at 0.7 microg x kg(-1) x hr(-1) after a bolus infusion at 6.0 microg x kg(-1) x hr(-1) for 10 min. All patients received total intravenous anesthesia with propofol and fentanyl., Results: Mean effect-site concentration of propofol was significantly lower in the DEX group than in the control group (1.9 +/- 0.3 microg x ml(-1) vs 2.5 +/- 0.8 microg x ml(-1)). Mean effect-site concentration of fentanyl in the DEX group was significantly lower than that in the control group (1.93 +/- 0.41 ng x ml(-1) vs 2.67 +/- 0.70 ng x ml(-1)., Conclusions: The combined use of dexmedetomidine decreases anesthetic requirements in cardiovascular surgery.

We performed two successive operations in a 39-year-old pregnant woman with myasthenia gravis (MG) with perioperative administration of dexmedetomidine. The first was an emergency cesarean section at 28 weeks' gestation. The patient was administered vecuronium, a muscle relaxant during the operation. She was sedated with dexmedetomidine for prolonged postoperative intubation until she was conscious and the effects of vecuronium had worn off. Extubation was successfully performed within half an hour of regaining consciousness. The second operation was an extended thymectomy performed under general anesthesia. Dexmedetomidine was administered intravenously as an adjunctive anesthetic without vecuronium. Extubation was successfully performed immediately after the operation. Here, we report a successful perioperative management with dexmedetomidine in a patient with MG, without any complications. Although dexmedetomidine has been considered useful for perioperative management of patients with MG, further consideration regarding its use in such cases is needed.

We report a case of transfusion-related acute lung injury (TRALI) during coronary artery bypass surgery. A 73-year-old man developed severe hypoxemia after transfusion of platelet concentrate just before completion of surgery. The possibility of cardiogenic pulmonary edema was excluded by transesophageal echocardiography. A chest X-ray showed bilateral pulmonary edema, suggesting TRALI. Steroid therapy and administration of sivelestat sodium hydrate and vasopressors were started. The patient's PaO2 /FIO2 ratio increased from 56 to 223 within 12 hrs. Anti-HLA and antigranulocyte antibodies were detected in the donated blood products. We assume that the cause of this case was an immune reaction through anti-HLA and/or antigranulocyte antibodies. TRALI is a potentially life-threatening, underrecognized and under-reported complication of transfusion. A better understanding and awareness is needed for medical staffs.

Background: Objective structured clinical examination: OSCE is now widely used in educational scene in medical schools before medical students start their clinical training. However, the utility of OSCE on BLS education has not been confirmed yet. The effect of OSCE on BLS education was examined using questionnaires., Methods: Questionnaires on knowledge of resuscitation were distributed to 166 medical school students (100 students in 1999 semester without OSCE, 66 in 2004 semester with OSCE). The questionnaire included 13 questions based on the 1992 or 2000 guidelines for cardiopulmonary resuscitation. Six out of 12 questions were defined as "skill related questions" and the student who correctly answered all these "skill related questions" were thought to be competent for providing adequate BLS., Results: Competent student ratio was significantly higher in students with OSCE (48%, vs 20% without OSCE, P < 0.001). Thus OSCE was useful for medical student to establish BLS knowledge when compared with students without OSCE. However, this result also revealed that the acquired knowledge through OSCE did not last long. Although 98% of students actually passed OSCE, only half of them were competent on paper test during clinical training., Conclusions: OSCE improved medical students' knowledge of BLS, but did not contribute to prevent forgetting for a long time. Thus, reeducation in BLS is still necessary for students after passing OSCE.