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Background Rocuronium bromide (Rb) is a rapid onset, intermediate-acting neuromuscular blocking agent that is suitable for continuous administration. The appropriate rate of rocuronium administration is, however, difficult to determine due to large interindividual differences in sensitivity to rocuronium. The aim of this study was to clarify whether the simulated rocuronium concentration at the time of recovery to %T1 > 0 % after the initial administration of rocuronium is a good indicator of optimal effect-site concentrations during continuous rocuronium administration. Methods Twenty-one patients were anesthetized with propofol. After induction, Rb 0.6 mg/kg was administered intravenously, and nerve stimulation using the single stimulation mode was conducted every 15 s. When %T1 recovered to >0 % after the initial administration of Rb, the effect-site concentration of rocuronium, calculated by pharmacokinetic simulation with Wierda's set of parameters, was recorded and defined as the recovery concentration (Rb r.c.). The administration rate of rocuronium was adjusted to maintain the Rb r.c. during surgery. Rb administration was discontinued just before the end of surgery, and the recovery time until %T1 > 25 % was recorded. Plasma Rb concentrations were measured at 1 and 3 h after the initiation of continuous Rb administration. Result The mean Rb r.c. was 1.56 ± 0.35 [mu]g/ml, with minimum and maximum values of 1.09 and 2.08 [mu]g/ml, respectively. The %T1 did not increase above 10 % in any of the patients during continuous administration of Rb, and the recovery period to %T1 > 25 % ranged from 9 to 29 min. The effect-site concentrations of Rb calculated with Wierda's parameters significantly correlated with plasma concentrations (P < 0.01) at both 1 and 3 h after the initial administration of Rb. Conclusion The results suggest that our method may be one of the most reliable protocols for the continuous administration of Rb described to date for maintaining suitable muscle relaxation during surgery without excessively prolonged effects., Author(s): Takahiro Moriyama[sup.1] , Akira Matsunaga[sup.1] , Osamu Nagata[sup.1] , Kei Enohata[sup.1] , Tomomi Kamikawaji[sup.1] , Erika Uchino[sup.1] , Yuichi Kanmura[sup.1] Author Affiliations: (1) Department of Anesthesiology and Intensive Care, [...]

We present a patient with atrial fibrillation (AF) in whom a left atrial (LA) thrombus might have formed during laparotomy despite bridging anticoagulation therapy. No evidence of thrombus was detected by transesophageal echocardiography (TEE) at the start of surgery; however, a thrombus measuring 13 x 10 mm was found in the LA appendage by the end of the procedure, suggesting that thrombus might develop intraoperatively in patients with AF even when bridging anticoagulation is properly established. Intraoperative TEE can assist in detecting intracardiac thrombus in patients with AF regardless of their anticoagulation status and provides a tool for intervention to prevent systemic embolization. Keywords Atrial fibrillation * Thrombus * Bridging anticoagulation therapy, Introduction Atrial fibrillation (AF) is the most common perioperative cardiac arrhythmia. Its incidence increases with age, affecting 0.7 % of patients aged 55-59 years, increasing to 17.8 % in those [...]

Background Postanesthetic shivering can be triggered by surgical stress and several aspects of anesthetic management and is frequently preceded by a decrease in peripheral blood flow due to thermoregulatory vasoconstriction. As perfusion index correlates with peripheral blood flow, we examined whether perioperative perfusion index, measured using pulse oximetry, might be correlated with post-anesthetic shivering. Methods Twenty-eight patients presenting for elective abdominal surgery were enrolled. Core (esophagus) and peripheral (finger) temperatures and perfusion index were recorded in the perioperative periods. Correlations between perfusion index and peripheral temperature and core-to-peripheral temperature gradient were then explored. Plasma levels of epinephrine and norepinephrine were also measured. The extent of shivering was graded after emergence from anesthesia. Results Perfusion index declined before emergence from anesthesia in patients who then developed post-anesthetic shivering. This coincided with the time at which the difference between core and peripheral temperature became dissociated and peripheral temperature declined. Perioperative perfusion index was correlated with peripheral temperature and peripheral-core temperature gradient. Perfusion index at closure of the peritoneum predicted postanesthetic shivering and was significantly correlated with the extent of shivering. Plasma levels of both epinephrine and norepinephrine were significantly elevated after shivering events. Conclusions Perfusion index was significantly lower in patients with postanesthetic shivering before emergence from anesthesia, indicating that measurement of perfusion index during and before the end of anesthesia might be a useful means of predicting postanesthetic shivering. Keywords Postanesthetic shivering * Perfusion index * Core-to-peripheral temperature gradient, Introduction Postanesthetic shivering occurs in approximately 40% of unwarmed patients recovering from general anesthesia and is associated with substantial adrenergic activation and discomfort [1]. Shivering can increase tissue oxygen consumption [...]

Purpose The objective of this study was to confirm the renal protective effect of remifentanil-based anesthesia in perioperative adult patients with chronic kidney disease (CKD). Methods A total of 90 non-dialysis perioperative adult patients with CKD, with preoperative estimated glomerular filtration rate from creatinine (eGFRcreat) values of lower than 50 ml/min/1.73 [m.sup.2], who had undergone orthopedic surgery under general anesthesia were retrospectively selected. The subjects were divided into two groups according to whether or not remifentanil was used for anesthesia management: group R, in which remifentanil was used for anesthesia management (n = 45), and group NR, in which remifentanil was not used for anesthesia (n = 45). eGFRcreat was measured pre-surgery (pre), 7 days after surgery (day-7), and 14 days after surgery (day-14). Results In group R, both day-7 eGFRcreat (52.2 [+ or -] 17.0 ml/min/1.73 [m.sup.2]) and day-14 eGFRcreat (49.7 [+ or -] 15.5 ml/min/1.73 [m.sup.2]) were significantly higher than the pre eGFRcreat (40.7 [+ or -] 7.5 ml/min/1.73 [m.sup.2]) (day-7: p < 0.01; day-14: p < 0.01). In group NR, on the other hand, pre eGFRcreat (37.8 [+ or -] 7.6 ml/min/1.73 [m.sup.2]), day-7 eGFRcreat (41.2 [+ or -] 10.9 ml/min/1.73 [m.sup.2]), and day-14 eGFRcreat (40.2 [+ or -] 10.5 ml/min/1.73 [m.sup.2]) values were similar. Furthermore, both day-7 eGFRcreat and day-14 eGFRcreat were significantly higher in group R than in group NR (day-7: p < 0.01; day-14: p < 0.01). Conclusions Our findings suggest that anesthesia management using remifentanil may have a renal protective effect in perioperative adult CKD patients undergoing orthopedic surgery. Keywords Renal protective effect * Remifentanil * Chronic kidney disease (CKD) * Estimated glomerular filtration rate from creatinine (eGFRcreat), Introduction According to a survey conducted by the Japanese Society of Nephrology [1], the estimated number of adult patients with chronic kidney disease (CKD) in Japan is approximately 13.3 million [...]

A study was conducted to examine the redox changes in heme a + a3 and copper in cerebral tissue as related to the mitochondrial energy state. Near-infrared spectroscopy was performed to measure the redox behavior of copper. The findings illustrate a similarity between the redox behavior of copper and the reduction of heme a3 and heme a. The results indicate that rapid reduction of heme a can precede decreases in adenosine triphosphate levels which can aid in monitoring tissue oxygenation and energy states.

Controlling stress responses associated with ischemic changes due to bleeding and ischemia/reperfusion injury is essential for anesthetic management. Endogenous carboxyhemoglobin (COHb) is produced in the oxidative degradation of heme proteins by the stress-response enzyme heme oxygenase. Although the COHb level is elevated in critically ill patients, changes in endogenous COHb during anesthesia have not been well investigated. Therefore, we evaluated changes in endogenous COHb levels in patients undergoing liver resections with inflow occlusion. Levels of COHb were significantly increased after the Pringle maneuver. The inflow occlusion time in patients with increased COHb after the Pringle maneuver (δCOHb > 0.3 %) was significantly longer than in patients without increased COHb (ACOHb < 0.3 %) (P = 0.01). In addition, COHb changes were correlated with inflow occlusion time (P = 0.005, [R.sup.2] = 0.21). Neither total blood loss, transfusion volume of packed red blood cells, operation time, nor anesthetic time differed between patients with and without increased COHb. The results indicated that endogenous COHb levels were increased by inflow occlusion in patients undergoing liver resections, which suggests that changes in COHb may correlate with hepatic ischemia/reperfusion injury induced by inflow occlusion. Keywords Endogenous COHb * Inflow occlusion * Liver resection, Abbreviations AST Aspartate transaminase ALT Alanine transaminase CO Carbon monoxide COHb Carboxyhemoglobin Fi[O.sub.2] Fraction of inspired oxygen Hb Hemoglobin PRBC Packed red blood cells Carbon monoxide (CO) is endogenously generated [...]