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In recent years, attention has been focused on environmental exposure of anticancer drugs, and guidelines for occupational exposure measures in cancer drug therapy have been created in Japan. Exposure measures related to the preparation and administration of anticancer drugs are being standardized. Although exposure measures have been implemented for the preparation and administration of the infusion pump(IP)used for continuous fluorouracil administration for 46-hour in FOLFOX and FOLFIRI therapies, which are standard chemotherapies for colorectal cancer, needle-removal procedures after the end of administration have not been investigated. Therefore, in this study, we investigated anticancer drug exposure at the time of IP needle removal to establish a safe needle-removal procedure from the viewpoint of anticancer drug exposure countermeasures. The results suggest that the IP's clamp lock position and the pulsing flush of the Huber needle may reduce antineoplastic exposure. In the future, we would like to consider this an educational method for needle-removal techniques.

To make a good end at home and provide good palliative care for patients with cancer are urgent issues in Setagaya ward, as shown by certain statistics. Medical opioids are greatly needed for palliative care; as patient controlled analgesia(PCA) develops, it can lead to decisions by patients and their families to receive end-of-life care at home because the patient can choose to receive the same advanced palliative care received at the hospital. With in-home palliative care, given the rapid change in the medical condition of the patient and the sentiment of the family, the role of pharmacists is to quickly and reliably supply the pharmaceuticals and medical equipment that doctors need. The following are important in order to enable this; 1 ) a pharmacy stocked with medicalopioids in accordance with needs, 2 ) a pharmacy with a system that can provide support quickly, 3 ) the presence of people who understand the area of resources, and 4 ) a constant face-to-face relationship. The "Sakura-HOPPS(Sakurashinmachi Homecare Pharmacists PartnershipS)"is a group intended to provide exchange and cooperation of pharmacists beyond the framework of organizationalaffil iation, and authors hope to encourage the participation of increasingly more pharmacists to develop a close-cooperation system of acute care hospitals and community medical/home care.

An accurate continuous intravenous injection via a peristaltic finger infusion pump has been utilized at outpatient clinics recently. An infusion element designed for this pump is necessary for the accurate handling of the pump, and for proper use of this equipment, we need accurate information. Our experiments have shown that medication administration has occasionally been incomplete at the calculated input time when a peristaltic finger infusion pump has been used. In this paper, we have investigated the cause of the delay in the administration time and the effect of the attachment procedure using a combination of features from three kinds of such infusion pumps and five kinds of exclusive polyvinyl chloride (PVC) infusion sets, under various conditions. Our results suggest that the time required for complete administration was correlated to the input time when five kinds of PVC tubing without stretching were attached to three kinds of peristaltic finger infusion pumps (R(2)=0.9998-1.0000). However, when the PVC tubing was stretched 1-3 cm and was attached to the pump, the time required for complete administration of the solution was prolonged compared to the recommended listed input time (p<0.01-0.05, ANOVA, Tukey-Kramer multiple comparison). Therefore, we suggest that the procedure technique used by the medical staff and involving the infusion pump adversely prolonged the time required for completion of the administration of medication. In our opinion, pharmacists must provide information concerning not only the drugs, but also the medical devices used to the physicians and nurses.

Background: In this study using 3 different PCA devices (Baxter infuser LVBB +PCM 2 ml: Pump B, Coopdech Balloonjector +PCA 3 ml: Pump C, Rakuraku fuser +PCA 3 ml: Pump S), we investigated how easily PCA devices could be handled., Methods: In this study with 42 volunteers (14 elders and 28 nurses), we compared 3 PCA ejection volume and ejection rate among three PCA devices. PCA ejection rate was defined as the ratio of actual ejection volume to the maximum ejection volume (MEV) of each PCA device., Results: Although not only elders but also nurses failed to produce accurate PCA ejection volume in the Pump B, Pump S could provide the MEV even by elders. In the Pump C, approximately 80% of MEV could be achieved by nurses, but 60% of MEV by elders (P < 0.05)., Conclusions: Our data suggested that accuracy of PCA ejection volume might be dependent on PCA device.

A 6 1-year-old man with unresectable multiple hepatic metastases after resection of sigmoid colon carcinoma was treated with irinotecan and infused 5-fluorouracil (5-FU) plus Leucovorin (FOLFIRI). Since the levels of tumor markers increased, the 5-FU dose was increased from 2,700 to 3,000 mg/m2 using a Jackson-type pump and an extended infusion time of 53 hours. The blood level of 5-FU was 507 ng/mL 16 hours after starting the infusion. The pump was then changed to a bottle-type pump with the same dose of 3,000 mg/m2. At 16 hours, the 5-FU level was 964.5 ng/mL. The areas under the concentration vs. time curve (AUC mg・h/L)were 21 and 44 mg・h/L for the Jackson- and bottle-type pumps, respectively. Owing to the development of Grade 3 stomatitis and hand-foot syndrome, 5-FU was reduced to 2,700 mg/m2 with a bottle-type pump. The AUC decreased to 27 mg・h/L, but the liver metastases were reduced and the adverse effects subsided to Grade 1. This case shows that individual dose adjustment of 5-FU to the appropriate AUC based on pharmacokinetic monitoring of the blood 5-FU level can improve the response, reduce adverse effects, and have a clinical benefit.

In 2014, we reported the first trial based on outpatient parenteral antimicrobial therapy (OPAT) with continuous infusions in Japan. Following this, we found many patients who were eligible for OPAT but could not undertake it owing to difficulties in accessing the clinic daily. To overcome this problem, we created a model in collaboration with visiting nursing stations and started providing OPAT with the services. We report herein on a summary of the investigation of the first 10 patients treated under this model. We collected data pertaining to diseases, organisms, antimicrobials, treatment duration, bed days saved, outcome, readmission rate, and cost reductions associated with these patients. The most commonly targeted disease was osteomyelitis, followed by infective endocarditis. The condition of nine of the patients was complicated by bacteremia. The most commonly targeted organism was Staphylococcus aureus. Cefazolin was the most frequently prescribed antimicrobial, followed by Penicillin G. The median duration for OPAT was 12 days (range: 5-23 days). The total number of bed days saved was 129. All patients completed the planned OPAT. Eight patients were cured and two showed improvement. Only one patient was readmitted within a month after the completion of therapy. The estimated medical cost reduction was 496,540 yen, which is approximately 4,200 US dollars. Collaboration with visiting nursing stations provided OPAT to the patients who had difficulties in accessing the clinic daily. Our study shows that OPAT administered by continuous infusion in collaboration with home-visit nursing services would be a safe and feasible practice for efficient bed utilization and medical cost saving.

Intravenous azithromycin (AZM) was approved for use in December 2011 in Japan. In general, intravenous AZM injections are diluted to 1 mg/mL, with a total infusion volume of 500 mL to avoid phlebitis. Patients in intensive care units (ICUs) require small infusion volumes. We retrospectively evaluated the total AZM infusion volume in 65 ICU patients receiving AZM treatment from December 2011 to August 2014. Thirteen patients (20.0%) received a reduced volume [100 mL (5 mg/mL) or 250 mL (2 mg/mL)] using an infusion pump over 2 h. No peripheral phlebitis was observed in any patient. Based on this result, it is assumed that AZM can be safely administered to ICU patients even though the volume of solvent is reduced. AZM is widely recommended for the treatment of community-acquired respiratory infections and is used in patients with severe infections. Further investigation is required in additional patients to understand the effects of AZM volume reduction in greater detail.

Baclofen, a gamma-aminobutyric acid receptorB, agonist, is used to reduce symptoms of spasticity (hyperreflexia, increases in muscle tone, involuntary muscle activity), but the adequate baclofen dose in each diseases is unclear. The aim of our study was to evaluate how dosage level improves the symptoms of spasticity. 25 weeks observational longitudinal follow up study assessed 16 patients who received intrathecal baclofen given by a programmable pump. Clinical efficacy was assessed by the Ashworth scale related with the dose of baclofen. Compared with pretreatment values, there was an improvement in clinical efficacy, but the baclofen dose needed for hereditary spastic paraplegia (HSP) was significantly smaller than that in other diseases. The result shows the importance of knowledge of the adequate baclofen dose in each disease in that baclofen causes some clinically significant adverse reactions.

Therapy with mFOLFOX6/FOLFIRI used in treating colorectal cancer is typical of the regimens performed in outpatient settings. In this therapy, 46-h continuous infusion of 5-fluorouracil (5-FU) with concomitant oxaliplatin and irinotecan hydrochloride is conducted. The portable continuous infusion pump that makes continuous infusion possible has a non-electric structure, so variation in the infusion rate is seen. There are known effects of 5-FU concentration and temperature, and many studies have reported on the precision. In our hospital, we have experienced many cases of incomplete infusion and delays for the above reasons. We changed the specifications of the infusion pump to correspond to the kinematic viscosity of 5-FU and made all drug solution amounts uniform. We measured the time required to administer the drug solution from the time the infusion was started (recorded by a nurse) and the time it was completed (recorded by the patient), and confirmed the precision of the pump after the changes were made. It was found that while there was a decrease in the infusion rate at which the effect of the kinematic viscosity of 5-FU is seen, the mean infusion time was kept to within 46+/-10% hours in more than 90% of patients. There were no effects from concentration differences in 5-FU, and the completion time was reduced. The management and lifestyles of individual patients are potential factors in precision errors, and it is important to explain in advance to patients the necessity of secure fixation and infusion pump problems that might occur.

We formerly reported the most suitable volumes of medicinal solution for continuous 5FU infusion over 46 hours in the FOLFOX6 and FOLFIRI regimens, respectively, by analyzing the relation of the total volume of the medicinal solution in a portable disposable infusion pump (SUREFUSER A) and the duration of infusion using a regression analysis. A total infusion time of about 48 hours was obtained. As the ambient temperature increased, however, we noticed that the continuous 5FU infusion finished earlier than anticipated. Using an additional analysis, we found that not only the medicinal solution's original coefficient of viscosity, but also the ambient temperature influenced the duration of infusion. Here, we report that the speed of continuous 5FU infusion increases as the coefficient of viscosity decreases in response to increases in ambient temperature. Thus, the composition of medicinal solutions and the ambient temperature must be considered to ensure a correct duration of continuous infusion.

A portable infusion pump is essential to sustain the 46-hour continuous administration of 5-fluorouracil in the folinic acid, fluorouracil, and oxaliplatin (FOLFOX) and folinic acid, fluorouracil, and irinotecan (FOLFIRI) protocols in colorectal cancer chemotherapy. However,the accuracy of the 5-fluorouracil dose administered via the infusion pump and patient compliance varies because the infusion rate changes depending on the viscosity of the drug, temperature, etc. In addition, the termination of administration based on the patient's judgment may influence these factors. In the present study, the amount of 5-fluorouracil remaining in the infusion pump and the administration time were investigated. As a result, the median amount that was found to remain in the pump was 49 mg, which was 2.0% of the average dosage, and an median administration time delay of 70 min was obtained. A questionnaire survey revealed that a majority of the patients felt insecurity about in adequate administration and administration time delays. These results indicate that customizing capacity modulation in the infusion pump corresponding to the patient's usage or seasonal variability of air temperature, and patient education may be important to improve patient compliance.

We report here two patients with chronic disseminated intravascular coagulation (chronic DIC) secondary to aortic aneurysm, who were successfully treated with continuous subcutaneous infusion of heparin. The patients were 69- and 89-year-old males, who were admitted to our hospital because of thrombocytopenia and marked bleeding tendency. The underlying conditions were aortic dissection and aortic aneurysm, respectively. Coagulation test demonstrated that these patients had DIC, and a diagnosis of chronic DIC secondary to aortic aneurysm was made. Anti-coagulation treatment with oral camostat mesylate and daily subcutaneous infusion of heparin calcium was started. However, the treatment was insufficient to control chronic DIC, and these patients developed recurrent severe subcutaneous hemorrhages. Therefore, we attempted continuous subcutaneous infusion of heparin using a mobile infusion pump. This delivery of heparin markedly improved the coagulopathy, and the hemorrhagic episode disappeared with good compliance in the use of infusion equipment in these patients. Continuous subcutaneous infusion of heparin using a mobile infusion pump is effective and useful for long term treatment of chronic DIC by the outpatient department.

Two types of new electrical infusion pumps (pump) scheduled to be introduced to the Japanese market in this autumn, were featured focusing on patient controlled analgesia (PCA). For the successful introduction of PCA pumps into clinical practice, initial investments including both finance and manpower may be required. The clinical application of these PCA pumps should benefit both patients and medical staffs and gain more than the initial investment eventually.

Oxaliplatin, established as a therapeutic standard globally for advanced/recurrent colorectal cancer, was approved in Japan in April 2005. With this approval the FOLFOX and FOLFIRI regimens are often selected now as 1st or 2nd line treatment for advanced/recurrent colorectal cancer. Patients receiving these regimens needed to be hospitalized, because the total treatment period was as long as 48 hours. However, the patient who hoped for staying at home has become possible to spend more time at home by using a portable disposable infusion pump (SUREFUSER A) for continuous intravenous infusion of 5FU. The duration of continuous 5FU infusion is set at an average of 46 hours, however, large variations are observed in the duration of infusion. Due to limitation of time of a patient, there was a case that finished injection on the way. On the contrary, there was a case that finished in a much shorter time than the pre-designated 46 hours. In an attempt to resolve this problem, we analyzed the relation of the total volume of the medicinal solution in SUREFUSER A and the duration of infusion by regression analysis. The results revealed that it might be possible to bring the total infusion time to close to 48 hours by finding the most suitable volume for continuous 5FU infusion over 46 hours.

Cardiac anesthesia carries high risk because of the patient's cardiac and coexisting diseases and rapid and complex hemodynamic changes during surgery. We should be ready to treat hemodynamic changes which may rapidly deteriorate into a vicious cycle. Many potent drugs and life-support devices are used. The drugs should be properly labeled to avoid drug error. Prefilled drug syringes and ready-to-use bags are helpful to avoid mixture error. Syringe and infusion pumps should be properly set. All the infusion systems should be checked in a systematical way. Blood management including blood transfusion and coagulation is important. Heparin-induced thrombocytopenia (HIT) may cause thrombosis. Heparin and heparin-coated catheter should be avoided in patients with HIT. Causes of bleeding tendency should be sort out and treated accordingly. Protamine reactions including hypotension and pulmonary hypertension can be catastrophic. Lastly, intimate communication between surgeons, anesthesiologists, medical engineers, and nurses is essential to perform cardiac surgery safely.

We report our outpatient cases for home anti-cancer chemotherapy using a CV port and a portable pump system. A total of 119 patients with advanced and recurrent cancer were performed at an outpatient clinic or provided home anti-cancer chemotherapy since December 1996 until December 2005. Of these patients, 18 patients were provided home anti-cancer chemotherapy using a CV port and a portable pump system (5 with gastric, 4 colonic, 2 rectal, 1 lung, 1 hepatic, 1 duodenal, 2 breast, and 2 pancreatic). Fifteen patients had died, and 3 patients are alive and undergoing continuous therapy. The response revealed 3 cases with partial response, 13 cases with no change and 2 cases with progressive disease. No severe side effects were seen, and no troubles of catheter and port were experienced as well. Not only the treatment of outpatients for home anti-cancer chemotherapy was effective and maintained the patient's QOL, but also contributed to a marked decrease of medical costs compared to admission therapy.

Portable disposable infusers are widely used for treatment of various types of pain including postoperative pain and cancer pain, because they are simple to use, of lightweight, and inexpensive. In Japan, nine series of infusers are available from eight manufacturers. Volumes and flow rates of various infusers used for pain therapy widely vary from 40 to 500 ml and from 0.5 to 15 ml x hr(-1), respectively. Several infusers have flow selectors and/or patient-controlled analgesia circuits. Such a wide variety enables us to select optimal infusers for individual patients and thus to offer adequate pain control to those patients suffering from severe pain.

Electrical infusion pumps (pump) were featured with the focus on patient-controlled analgesia (PCA). The specification and functional aspects of four types of PCA pumps were briefly summarized and listed in two tables. The clinical application of these PCA pumps should benefit both patients and medical staffs. For the successful introduction of PCA pumps into clinical practice, a medical team must be organized, where not only anesthesiologists but also nurses, pharmacists, medical electronic engineers and surgeons are expected to participate.

Pain is the most popular complaint since the appearance of the human on earth, a very unpleasant feeling sometimes difficult to be treated. Therefore, we have many patients who complain of pain in our hospitals or clinics. When a patient with pain visits our institution, first of all, we must evaluate the grade of pain, and then start to treat the pain of the patient. Of course, we have many devices available to treat the patient with pain. In the following special articles, device for evaluation of pain, spinal stimulation device, device for electrical current therapy (ECT), LASER device for chronic and acute pain, epiduroscopy for lumbago, as well as disposable infusion pump for postoperative pain and cancer pain are described. The mechanism of pain may be understood by patients themselves. However, devices in these articles are very useful for the treatment of pain, especially intractable pain. I feel very happy if these articles contribute greatly for the treatment of patients with pain.

During the period of 1990-2005, 701 patients with the hepatocellular carcinoma were treated with intra-arterial infusion of 5-FU and epi-adriamycin with or without Lipiodol chemoembolization employing an implantable infusion port system. In 70% of the patients treated, an objective response was observed with marked regression of tumor and decrease in tumor marker (AFP and PIVKA-II). Also 1,091 patients with the metastatic liver cancer of colon, rectum, stomach and pancreas were treated with the same procedure employing 5-FU, mitomycin C, adriamycin, or epi-adriamycin. In more than 80% of the patients treated, an objective response was observed with marked regression of tumor and decrease in tumor marker (CEA, CA19-9, TPA, DUPAN-2, SPan-1). Intra-arterial infusion chemotherapy employing an implantable port system also proved to be a promising treatment modality for most of the intractable head and neck cancer, breast cancer and a few of the pancreas cancer.

We evaluated diagnosis and treatment of four cases of meningeal carcinomatosis associated with primary lung cancer: case 1; small cell carcinoma (64 years old), case 2; small cell carcinoma (50 years old), case 3; adenocarcinoma (53 years old), and case 4; adenocarcinoma (55 years old). Determination of tumor markers in cerebrospinal fluid (CSF) together with the MRI findings that Gd-DTPA-enhanced T1-weighted image showing high intensity signal along the spinal cord was clinically useful in the diagnosis of meningeal carcinomatosis. Two of four patients received intrathecal chemotherapy and/or CSF drainage through Ommaya-Reservoir, resulting in dramatic improvement of various symptoms such as motor weakness and vesicorectal disorder. Intrathecal chemotherapy and placement of an Ommaya-Reservoir for CSF drainage should be considered to provide better Quality of Life (QOL) when patient can tolerate it.

Background: Although patient-controlled epidural analgesia (PCEA) is widely known to provide good pain control after abdominal surgery, it has not been popular in Japan. We evaluated the effects of PCEA with background infusion after major abdominal surgery., Methods: Ninety patients scheduled for abdominal surgery were randomly allocated to two groups by treatment with postoperative epidural analgesia: infuser group (n = 48); continuous infusion 5 ml.hr-1 or PCEA group (n = 42); background infusion 5 ml.hr-1, PCEA 3 ml and lock out 30 min. Microject (Sorenson Medical Co, U.S.A.) was used for PCEA machine. 0.2% ropivacaine 100 ml with fentanyl 500 micrograms was administered into the epidural space in both groups., Results: Postoperative visual analogue scale (VAS) at rest and coughing were about 10 mm and 40 mm in both group, respectively, and there were no significant differences between the groups. NSAIDs were effective for rescue analgesia in infuser group to improve postoperative pain as PCEA. Vomiting and sedation were more frequent in infuser group than in PCEA group. Empty battery and machine troubles of unknown origin were observed in 2 and 4 patients, respectively in PCEA group., Conclusions: PCEA with background infusion could improve the management of postoperative pain, and adequate program of PCEA is important to reduce postoperative pain and its side effects.

Background: We experienced a case of inadequate sedation because of inappropriate use of TCI system for fentanyl., Methods: We evaluated the blood and effect-site concentrations of propofol and fentanyl calculated by a pharmacokinetic simulation model in which the administration of one drug was managed with target-controlled infusion pump set for another drug., Results: In case propofol was administered with an effect-site-steering TCI system for fentanyl, the blood concentration of propofol increased within the first few minutes, especially immediately after starting the infusion, decreased for the next 10 minutes, and then was stabilized at a level of 0.7 times the target concentration. When fentanyl was administered with a blood-steering TCI for propofol, the calculated blood concentration of fentanyl was almost equal to the target concentration in the first few minutes, and then gradually increased until reaching 2.21 times the target concentration, at 240 minutes. Furthermore, the propofol concentration and the fentanyl concentration showed small differences between the target and calculated concentrations when the infusion time was not so long., Conclusions: When the administration time is short, the anesthesiologist must be aware of the difficulty in distinguishing the human error of choosing one drug for the TCI system for another drug.

Background: We have been offering active postoperative analgesia service (PAS). In order to further enhance the quality of PAS, we reviewed 1500 cases of postoperative continuous epidural analgesia (PCEA)., Methods: Postoperative patients received epidural administration of a mixed analgesic solution employing bupivacaine, morphine, or fentanyl using a portable disposable infuser pump (PDIP) for at least 72 hours. Analgesic effects were assessed by using Prince Henry's scoring and the demand for additional analgesics. The frequency and causes of discontinued infusion were also evaluated., Results: 83.9% of cases showed no complications. However, in 4.7% of cases infusion was discontinued because of side effects (nausea, vomiting, pruritus, lower limb motor block, and hypotension, etc.), in 4.1% because of dislodgment of the epidural catheter, in 3.4% because of disconnection, in 2.0% because the patient removing the catheter, and in 0.8% because of the condition of the catheter insertion site., Conclusion: These results indicate that to improve our method of PCEA with PDIP, we must re-assess our regimen used for continuous epidural infusion for postoperative pain relief, and develop measures to prevent side effects and complications.

We used a Baxter AS 50 syringe pump for intravenous anesthesia with propofol, and compared it with a Grasby 3500 and a Terumo STC-525 X pumps, which are specifically designed for propofol infusion. The AS 50 pump is a programmable syringe infusion pump, which allows us to register up to 70 drug names in 10 categories and various infusion modes for drugs. There are 14 types of continuous infusion mode, a custom dilution mode, and three types of time infusion modes. The continuous infusion mode in mg.kg-1.h-1 is available for propofol anesthesia. Operation of this pump is simple and user-friendly, as with for the other propofol-specific pumps. Although the AS 50 pump is limited to a maximum bolus rate of 438 ml.h-1, this restriction is not a serious problem in clinical practice. The AS 50 pump is also equipped with an RS-232 C digital interface port to allow external remote monitoring or automated control. On-line simulation of blood propofol concentration is possible with a simulation program such as Propofol-Mon. Our impression is that the AS 50 pump is compact, easy to use, accurate and reliable for propofol anesthesia.

A 67-year-old female with rectal cancer and multiple liver metastases underwent low anterior resection by total mesorectal excision (TME), cholecystectomy and hepatic arterial cannulation in June 1995. She was treated with hepatic arterial infusion chemotherapy (HAI) (5-FU 600 mg/m2/day x 2 days/w) and oral UFT (400 mg/body, 5 days/w) once a week for 6 months on an outpatient basis. As the metastatic foci of the liver significantly decreased (83.3%) and extrahepatic disease were not observed, partial resection of the liver (second-look hepatectomy) was performed in March 1996. She continued arterial infusion PMC and venous infusion PMC as an outpatient. During the follow-up period a lung metastasis appeared in November 1997. Her regimen was changed to modified PMC with MMC (mitomycin C) and CPT-11. She has been managed at our outpatient clinic while the lung metastasis remained but with no liver metastasis for 57 months after the first operation, until the present. Second-look hepatectomy and PMC with a two-way port system was a useful option for unresectable hepatic metastases from colorectal carcinoma.

In 40 females undergoing gynecologic laparotomy, lumbar epidural analgesia using a disposable infusion pump was continued for postoperative 48 hours. Then the analgesic effect of epidural bupivacaine (4.8 mg.kg-1) plus fentanyl (12 micrograms.kg-1) diluted with normal saline was prospectively compared between the two groups; high concentration/low volume group (HC/LV, 96 ml of total volume and 2 ml.h-1 of infusion rate, n = 20) versus low concentration/high volume group (LC/HV, 240 ml of total volume and 5 ml.h-1 of infusion rate, n = 20). On postoperative day 1, LC/HV group showed the significantly lower visual analog scale and verbal pain score at rest than HC/LV group (P < 0.05). No significant differences in the incidence of side effects were observed between the groups. These results suggest that when the equivalent dose is given, the volume rather than the concentration of the solution is important for postoperative continuous epidural analgesia with the combination of bupivacaine and fentanyl.

Otsukadai Pharmacy compounded morphine chloride for injection in 32 cancer patients. In 22 cases we compounded morphine into a TPN bag. However we recommend using an infusion pump to control the patient's pain at home. We think that we need a system with a pharmacy for cancer patients before they leave the hospital for home care.

We assessed 23 patients who underwent surgical therapy of hepatectomy or microwave coagulation therapy (MCT) for bilobular multiple hepatic metastatic foci following curative resection of the primary lesion of colorectal cancer. Hepatectomy was the first surgical therapy for 10 patients, and 6 of them received combined intra-arterial chemotherapy. All 13 patients in the MCT group received intra-arterial chemotherapy, and 8 of them underwent combined hepatectomy. The two-year survival rate of the hepatectomy group, classified according to the first surgical therapy, was 40% against 52% in the MCT group. In comparison with the H2 (2-5 foci) patients in the hepatectomy group, there were 7 H2 patients in the MCT group, and the two-year survival rate of these 7 patients was 50%. No significant difference was observed between hepatectomy and the MCT as the first surgical therapy. The survival rates of the 5 patients who received treatment for recurrence after the first surgery and of the 18 patients without any recurrence treatment were 80% and 40%, respectively. No significant difference existed between the two groups, but a p value of 0.06 was noted. MCT was considered to be useful local therapy for cancer as the first therapy and as a therapy following recurrence.

We evaluated efficacy of patient-controlled epidural analgesia (PCEA) using a disposable PCA device (3.0 ml type). Twenty-two patients for elective gynecological surgery were randomized into two groups. Patients of the continuous epidural group received epidural fentanyl (15 micrograms.ml-1) with bupivacaine (1.25 mg.ml-1) from a disposable infusion pump (infusion rate: 2.1 ml.hr-1). Patients of the PCEA group received the same anesthetic solution from the same infusion pump serially connected to the disposable PCA device. There were no significant differences in postoperative visual analogue scale (VAS) scores at rest and with movement between the two groups. However, VAS scores significantly decreased from 6.8 +/- 1.6 to 1.0 +/- 1.3 when the PCA device was used for severe pain. This suggests that segmental analgesic effect might be obtained by diffusion of anesthetic solution in the epidural space after 3.0 ml PCEA bolus administration. The incidences of side effects were similar in both groups. Respiratory depression and sedative effects were not observed in both groups. We conclude that PCEA using a disposable PCA device (3.0 ml type) seems to be effective for postoperative pain relief.

Continuous intravenous administration of Diprivan (1% propofol emulsion, P) is usually carried out using a syringe-pump or an infusion-pump to adjust the infusion rate. We assessed the accuracy of the infusion dose of P and the serum concentration of propofol by manual controls during anesthesia. Twenty eight patients, anesthetized with oxygen, P and vecuronium in combination with fentanyl and epidural block were randomly assigned to either of the following groups; P was administered using the drip-infusion (the group D, n = 14) or a syringe-pump (the group S; n = 14). In the group D, we used the drip-rate table to calculate the dose of P. We assessed (1) the total infusion volume of P which was calculated from the infusion rate and duration (Vc), and also measured by a calibrated cylinder (Vm) in the group D (n = 14) and group S (n = 14), and (2) the serum propofol concentrations 40 min after infusion of P (6 mg.kg-1.hr-1) were assayed using the HPLC. The Vc was well correlated with the Vm in the group D (r = 0.976) and in the group S (r = 0.974). Mean serum propofol concentrations of the group D and S were 2.50 +/- 0.57 and 2.35 +/- 0.62 micrograms.ml-1, respectively. The results suggest that the drip-infusion technique of P may be substituted safely by the syringe-pump for continuous total intravenous anesthesia.

We evaluated the accuracy of a new disposable pump (Coopdech Syrinjector), which employed the negative pressure made by injecting fluid into the pump for continuous epidural infusion. Thoracic epidural catheter was placed at the T6-T8 level prior to the lung surgery. The continuous epidural infusion of 0.25% bupivacaine at 2 or 3 ml.h-1 was started immediately after the surgery. The residual volume of bupivacaine was recorded. From our results, the injection speed of Syrinjector was satisfactory for clinical use of continuous epidural infusion of bupivacaine. However, when this pump is reused or the volume of the residual local anesthetics is less than 10 ml, the infusion accuracy will be potentially imprecise.

These studies were designed to evaluate the efficacy, toxicity, and resulting quality of life (QOL) of outpatient chemotherapy with infusional 5-FU for advanced gastrointestinal cancer. Schedule, sch. A: Treatment consisted of CI 5-FU 200 mg/m2/day, days 1-28, IVB Leucovorin 20 mg/m2 q week. Fifteen patients with advanced gastrointestinal cancer were treated to maintain the efficacy of prior inpatient chemotherapy. Twenty-one patients treated with adjuvant chemotherapy were added to evaluate toxicity and QOL. The mean time to progression (TTP) was 2.6 months. Grade 2 toxicities were seen, including mucositis (23%) and diarrhea (7%). Hand-foot syndrome was seen 60% of patients. The mean QOL score was 89.5 +/- 7.8. Sch.B: Treatment consisted of weekly 24 h infusion of 5-FU 2,600 mg/m2. 5-FU was administered using a Groshong catheter and Baxter infusor LV5 (5 ml/hr). Nine patients with advanced gastrointestinal cancer were treated. Twenty-one patients were treated with adjuvant chemotherapy. The mean TTP was 3.6 month. Grade 2 toxicities were seen, including leucocytopenia (7%), mucositis (3%), diarrhea (10%), and nausea and vomiting (10%). The mean QOL score was 82.6 +/- 10.7. In conclusion, both 5-FU schedules are feasible for outpatient chemotherapy for advanced gastrointestinal cancer.

We developed a software to control a Graseby 3500 syringe pump for propofol infusion through the serial port of Apple Macintosh/Power-Macintosh computer. This software, "ConGrase", was developed with Metrowerks CodeWarrior Professional (CWP 1) and PowerPlant framework using C++. ConGrase communicates with the syringe pump at least every three seconds, and calculates the estimated blood concentration (EBC) of propofol based on the amount of propofol actually infused by applying either the Euler or Runge-Kutta method using the three-compartment pharmacokinetic model. The parameter sets reported by Gepts et al. are used. ConGrase was released at the 44 th Annual Meeting of the Japan Society of Anesthesiology, and is distributed freely. The mean and S.D. of the emergence EBC calculated by ConGrase were 1.22 micrograms.ml-1 and 0.16 microgram.ml-1, respectively. These values are almost the same as values already reported outside Japan. The necessary wake-up time can be calculated with this estimated concentration. With this system, anesthetists can control the EBC at the required level and avoid long delays before the patients wake up after anesthesia.

Epidural blockade with local anesthetic may cause hypotension resulting from sympathetic block and/or systemic effect produced by absorbed local anesthetic through epidural blood vessels. In the present study, we compared the hemodynamic effects of saline 0.5 ml.h-1, lidocaine 0.5 ml.h-1, bupivacaine 0.5 ml.h-1, lidocaine 2 ml.h-1, and bupivacaine 2 ml.h-1, which were given epidurally combined with morphine. There was not significant difference in hemodynamics among 5 groups. Continuous epidural infusion with a small dose of local anesthetic agent combined with morphine is unlikely to induce apparent hemodynamic effects during postoperative period.

We investigated the effectiveness of continuous arterial infusion of low-dose CDDP, 5-FU for residual cancer after cytoreductive surgery for advanced hepatocellular carcinoma. Thirty-one patients with unresectable advanced hepatocellular carcinoma were classified into two groups by adjuvant therapy after reduction surgery: 1) Low-dose FP Group: 17 patients; continuous arterial infusion of low-dose CDDP, 5-FU via implanted port system; 2) Conventional group: 8 patients; Lipiodolization (6 cases) and transcatheter arterial embolization (2 cases). The five-year survival rate in the low-dose FP group was 34.8%, the efficacy was 64.7%, CR: 6 (35.3%); PR: 5; NC: 4; PD: 2. Thus, continuous arterial infusion of low-dose CDDP, 5-FU was effective as adjuvant therapy in cytoreductive surgery for advanced hepatocellular carcinoma.

Hospice and palliative care have important roles for cancer patients in an incurable state to alleviate their total pain and to achieve the best quality of life. Interdisciplinary team-doctors, nurses, therapists, social workers and so on provide effective support in order to fulfill the varying needs of patients and families. Pain relief as a palliative medicine is most urgently required by seventy percent of patients on admission to our Hospice at the Salvation Army Kiyose Hospital. A case is presented with some comments on pain management. Music therapy is also introduced. This is one of the complementary methods for consolation of the mind and body of patients. Some of them seem to find it beneficial.

Continuous local chemotherapy has been evaluated as being an effective administration method and as a possible adjuvant therapy in the sensitivity aspect of the cell cycle for malignant glioma. However, neurotoxicity of anti-cancer agents in the normal brain and non-effective methods for the deeper part of the tumor seem to be the most serious problems. This study was initiated to evaluate histological findings, the uptake distribution, and neurotoxicity of the continuous local administration of isotope labeled anti-cancer agents in the brain tumor of rats. The experimental brain tumor of rats and the method of continuous local chemotherapy were as follows. The tumor was produced by intracerebral inoculation of cultured cells derived from rat brain tumor induced by Rous sarcoma virus (Kumanishi et al. strain). One week later Fluorouracil (5-6-3H) (17.7 Ci/m mol) and methotrexate (L-glutamyl 3-4-3H) (41.0 Ci/m mol) were administered into the brain tumors of rats utilizing a mini osmotic pump (Alzet Model 2001), respectively. We used five rats of various groups. The rats were sacrificed at various time intervals (6 hrs, 12 hrs, 24 hrs, 48 hrs, 72 hrs and 7 days). The tumor tissues for light microscopic autoradiography were fixed in 10% formalin for 24 hours. Sections for the light microscopic autoradiography were cut at 4 mu thick and coated with Sakura NR-M2 drips. Following exposure for one week at 4 degrees C, the sections were stained with Konidol X. Six hours after administration, slight radioactivity was distributed in the subarachnoid space and subpial brain tissue in the vicinity of the inserted tube. Twenty-four hours after administration, high radioactivity was clearly present in many tumor cells and phagocytes at the tube tip, but no radioactivity was observed in the deeper part of the tumor or normal brain tissue. In the vicinity of necrosis foci, acute toxic inflammation was also observed. In conclusion, this experimental study shows that these anti-cancer agents are capable of direct penetration into the neoplastic cells of an intracerebral tumor following continuous local administration. However, necrotic foci were small in size. The most serious side effect seemed to be the presence of acute toxic inflammation in the vicinity of the necrotic foci.

A program for on-line simulation of blood propofol concentration was developed. Various pharmacokinetic model programs are available for the estimation of intravenous anesthetic concentration. But manual entry of data such as body weight, rate of infusion and the timing of changing the flow rate is mandatory in these programs. This limited the use of these programs for investigational use only. In a new program, the data required such as total dose, flow rate, body weight and time were collected automatically on-line via the digital outlet of the syringe driven pump (Terumo STC525X, Japan and Graseby 3500, UK) to a personal computer (Apple Macintosh Power Book Duo230 or Power Book 520, USA). Based on the obtained data, pharmacokinetic model was solved with personal computer. Calculated blood concentrations of propofol were displayed in a numeric form and a trend graph was obtained. This program provides useful information for maintainance of anesthesia with propofol.

We tried home anti-cancer chemotherapy for patients with advanced or recurrent cancer of the digestive system, using two disposable balloon pumps connected to an implantable drug delivery system via central venous line. There were 33 patients under 75 years old, including 20 cases of gastric cancer, 9 cases of colorectal cancer, 2 cases of cholangiocarcinoma and 2 cases of esophageal cancer enrolled in this study. The protocol was combined chemotherapy with continuous intravenous infusion of 5-FU (300 mg/body/day) and low-dose intravenous injection of cisplatin (5 mg/body/day) in 10-day courses for two weeks, and it was repeated 3 times for 6 weeks. Because of side effects such as nausea, vomiting and bone marrow suppression, treatment was discontinued in 12 cases with peritoneal cancer infiltration. In two of 10 with estimable disease, the reduction of the metastatic lymph node was observed, but no effect was shown in the colorectal metastatic liver tumor. Thanks to the portability of the pump with this method, the patient need not undergo hospitalization. Moreover, there is no renal dysfunction or other major side effects, quality of life is not compromised and a return to family and social life is possible. Thus, if the patient cannot take the oral nutrition, it is easy to start home hyper-alimentation.

A new programmable syringe infusion pump, Auto Syringe Model AS 40 A, was evaluated for infusion of muscle relaxants, vasodilators and opioids in 4 surgical patients. Every drug mentioned above was easily adjusted according to surgical requirement in these patients. Auto Syringe Model AS40A is light and compact. Its major advantages lie in the mechanisms for delivery of a bolus dose and automated delivery of intermittent doses, automatic rate calculation, and the applicability to various sizes of syringes. Auto Syringe Model AS40A was found to be very useful for intravenous infusion of drugs.

Using a portable 0.5 ml.h-1 type infuser with Patient Control Module (Baxter infuser BB+ PCM), we compared patients receiving continuous epidural infusion with patients using self controlled analgesia system for postoperative analgesia after upper abdominal surgery. Twenty-one patients were randomized into three groups: group I (n = 7) received 20 micrograms.h-1 of buprenorphine (Bu) with additional 20 micrograms of Bu; group II (n = 7) 20 micrograms.h-1 of Bu plus 1 mg.h-1 of bupivacaine (Bup) with additional 20 micrograms of Bu plus 1 mg of Bup; group III (n = 7) 20 micrograms.h-1 of Bu plus 2 mg.h-1 of Bup with additional 20 micrograms of Bu plus 2 mg of Bup. In all three groups, patients received supplemental Bu 0.1 mg intramuscularly as needed. During 48-hours postoperatively, we evaluated verbal descriptor pain scale, sedative scale, visual analogue scale, supplemental doses of Bu, and side effects. Total doses of Bu during the first 12 hours were significantly larger than those during other 12-hour period in all the groups (P < 0.05). In each period during the 12 to 48-hours after operation, the percentage of the patients who needed no supplemental Bu was 71.4-100%, which is higher than during the 0 to 12-hours (47.7%). There was no significant difference in verbal descriptor pain scale, sedative scale, visual analogue scale, and the incidence of side-effect among the three groups. Continuous epidural infusion with Bu using a portable 0.5 ml.h-1 type infuser with patient control module was effective for alleviating postoperative pain except in the first 12-hour period. However, addition of Bup to Bu did not improve the quality of postoperative epidural analgesia.

A [15O]water production and infusion system was newly developed for blood flow study with positron emission tomography. The system utilizes a electrostatic cooling unit to liquify [15O]vapor in a coiled plastic tube. Labeled [15O]water is collected into an infusion syringe by a wash of the trapping tube with saline. The system is simple and efficient; the recovery rate of [15O]water is over 90% at 10 degrees C of cooling temperature.

We have performed combined chemotherapy with 5-FU, a biochemical modulator, and low dose CDDP for advanced or recurrent cancer of the digestive system. The therapy was effective in 37% of all cases and in 45.5% and 41.6% of esophageal and gastric cancer cases, respectively. In addition, few patients developed adverse side effects including renal disorders, one of the major side effects of CDDP. Therefore, we considered home anti-cancer chemotherapy feasible. For 27 outpatients with advanced cancer of the digestive system including 15 cases of esophageal cancer, 4 cases of gastric cancer, 3 cases of colon cancer, 4 cases of pancreatic cancer and 1 case of gall bladder cancer, 4 to 6 week home adjuvant chemotherapy was performed. The regimen comprised 1 week of oral administration of 300 mg/body/day of UFT-E granules and 5 days of continuous intravenous infusion of 25 mg/body/day of CDDP using an infusor pump. During the follow-up, 3 cases of catheter obstruction, 3 cases of catheter sepsis and 1 case of pneumothorax appeared. These complications all resulted from the catheter, and safe home anti-cancer chemotherapy could be continued because 5-FU and CDDP did not cause severe side effects.

This study was designed to evaluate the efficacy, toxicity, and quality of life (QOL) of outpatient chemotherapy with 5-FU and LV in advanced gastrointestinal cancer. Treatment consisted of CI 5-FU 450 mg/body/day, days 1-28, IVB LV 30 mg/body q wk (schedule, sch. A) and CI 5-FU 200 mg/m2/day, days 1-28, IVB LV 20 mg/m2 q wk (sch. B). 5-FU was administered with the Baxter infusor (0.5 ml/hr). Oral UFT (400-600 mg/day) was administered after these chemotherapy. Sixteen patients (pts) (sch. A 9 pts, sch. B 7 pts) with advanced gastrointestinal cancer have been treated to maintain the efficacy of prior inpatient chemotherapy. Twenty pts treated as adjuvant chemotherapy were added to evaluate toxicity and QOL. The median time to progression in sch. A was 3.0 months and sch. B was 2.4 months. Grade 3 or 4 toxicities of mucositis were seen 40% in sch. A and 0% in sch. B. Grade 1 or 2 skin toxicities were seen 100% in sch. A and 52% in sch. B. Mean score of QOL in sch. A was 78.0 +/- 11.5, sch. B was 89.5 +/- 7.8 ranked between inpatient chemotherapy (5-FU + CDDP 59.0 +/- 13.8) and UFT (91.8 +/- 6.1). In conclusion, these schedule of 5-FU and LV combination offers a high patient QOL and is suitable for advanced gastrointestinal cancer treatment.