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To evaluate the efficacy of nitric oxide (NO) inhalation against endotoxin-induced lung injury.Randomized prospective short-term study.University school of Medicine Laboratory.Animal experiment (using 16 Japanese white rabbits). The animals inhaled NO at a concentration of 10 ppm.The rabbits were randomly divided into the NO inhaling group (n = 7) and the control group (n = 9). Both groups received continuous infusion of 1200 mcg lipopolysaccharide (LPS) and the NO group inhaled 10 ppm NO during the LPS administration. In the control group, severe right ventricular (RV) failure was observed at 30-90 min of LPS infusion, and 4 of 9 animals died within 90 min of LPS infusion. In the NO group, none of the animals died and the early phase hemodynamic deterioration was milder than in the control group. But pulmonary gas exchange was not significantly different between the two groups throughout the study. At the end of the study there were no significant differences in any parameters of the surviving animals between the two groups.Although an improvement of pulmonary gas exchange was not demonstrated, NO inhalation (10 ppm) improved the outcome of severe RV failure caused by LPS infusion.

To evaluate the temporal changes in respiratory physiological dead space and dynamic compliance of the respiratory system during non-abdominal, upper abdominal and lower abdominal surgery under general anaesthesia with intermittent positive pressure ventilation.Thirty-four adult patients were studied (non-abdominal surgery, n = 8; upper abdominal surgery, n = 13 and lower abdominal surgery in lithotomy position, n = 13). Physiological dead space was measured using the single breath carbon dioxide test. The physiological dead space to tidal volume ratio (VD/VT), dynamic compliance of respiratory system, expiratory tidal volume and respiratory rate were measured 10 min after tracheal intubation, and 30, 60 and 120 min later.In lower abdominal surgery group, VD/VT was significantly increased at 120 min compared with 0 min (P = 0.005) and 30 min (P = 0.009). There were no significant differences in VD/VT between the three groups at any time point. Compliance decreased significantly in patients with upper abdominal (120 min) and lower abdominal surgery (60 and 120 min), but there were no significant changes during non-abdominal surgery.We found that the VD/VT increased in patients undergoing lower abdominal surgery in lithotomy and head down tilt, and compliance decreased in those undergoing upper abdominal and lower abdominal surgery over time.

To produce radiopaque silica (SiO2)-based fillers, zirconia (ZrO2) powders were mechanically added to SiO2 powders with ZrO2 content up to 40 wt%. We evaluated the radiopacity of experimental composite resins consisting of (Bis-GMA + TEGDMA + CQ + DMAEMA) monomer mixture (25 wt%) and admixed SiO2−ZrO2 fillers (75 wt%), and compared their radiopacity with those of human dentin and enamel. It became confirmed that the radiopacity of experimental composite resins increased linearly with zirconium content, while the composite resin containing 80 wt% SiO2-20 wt% ZrO2 filler possessed radiopacity similar to that of human enamel. It was proved that the radiopacity of the composites could be precisely controlled by adjusting ZrO2 content in SiO2−ZrO2 fillers.

Xenon at two different concentrations (30%, 60%) has no effect on diaphragmatic contractility. This study was undertaken to compare the effects of xenon and nitrous oxide (N2O), a commonly used and well-established gas anesthetic, on diaphragmatic contractility in dogs.Twenty-one pentobarbitone-anesthetized dogs were randomly divided into three groups of seven each: group 1 received xenon 30% (0.25 MAC) in oxygen; group 2 received N2O 47% (0.25 MAC) in oxygen; and group 3 received N2O 60% (0.32 MAC) in oxygen. Diaphragmatic contractility was assessed by transdiaphragmatic pressure (Pdi) at low- (20-Hz) and high-frequency (100-Hz) stimulation, after maintaining 60 min of stable condition. The integrated electrical activity of diaphragm (Edi) to each stimulus was measured.With an inhalation of xenon 30%, N2O 47%, or N2O 60%, Pdi and Edi at both stimuli did not change. No difference in Pdi or Edi was observed among the groups.When used at clinical concentration, xenon or N2O does not affect contractility and electrical activity of the diaphragm in dogs.

To compare the effect of Valsalva maneuver and 10 degrees Trendelenburg position on the right internal jugular vein (RIJV), we measured RIJV cross-sectional area using ultrasound imaging during these procedures. The study group consisted of 13 normal healthy volunteers (6 males, 7 females, aged 25-47) with no history of neck surgery or right internal jugular vein (RIJV) puncture. All ultrasound images were obtained at the level of the cricoid cartilage. The subjects were positioned supine, and the measurements were taken with the subjects supine, under Valsalva maneuver, and under 10 degrees Trendelenburg tilt position. The cross-sectional areas of the RIJV during Valsalva maneuver and 10 degrees Trendelenburg position compared to those with supine position were 314 +/- 162%, and 192 +/- 96%, respectively. We conclude that both procedures increase cross-sectional area of IRJV significantly and in this respect Valsalva maneuver is more effective than Trendelenburg position.

The main advantages of prostaglandin E1 (PGE1) for induced hypotension during neurosurgery include a rapid onset of action, a quick recovery from hypotension, lack of toxicity, maintenance of adequate perfusion to vital organs, and maintenance of cerebral blood flow reactivity to carbon dioxide during hypotension. However, there is no report that shows the effect of PGE1 on cerebral microvessel diameter and only a few data are available that show the effect of PGE1 on intracranial pressure. The aim of this study was to measure cerebral arteriole and venule diameters and intracranial pressure (ICP) during PGE1-induced hypotension to evaluate whether PGE1 is suitable for neuroanesthesia.We measured the effects of 0.1, 0.3, 1.0, 3.0, and 10.0 microg x kg(-1) x min(-1) of intravenous PGE1 on mean arterial pressure (MAP), cerebral arteriole and venule diameters and ICP in anesthetized rabbits.MAP decreased statistically significantly from baseline at the infusion rates of 1.0, 3.0, and 10.0 microg x kg(-1) x ml(-1). Arteriole diameter increased significantly from the baseline at the infusion rate of 10.0 microg x kg(-1) x ml(-1) (18% from control). Venule diameter did not change from baseline value at any infusion rate. ICP did not change from baseline value at any infusion rate.We conclude that PGE1 might be a suitable drug for induced hypotension in neurosurgery from the viewpoint of its small effect on the cerebral microvessels and ICP.

Diaphragmatic fatigue may contribute to the development of respiratory failure. We studied the dose-range effects of propofol on the contractility of fatigued diaphragm in dogs. Animals were divided into three groups of eight each. In each group, diaphragmatic fatigue was induced by intermittent supramaximal bilateral electrophrenic stimulation at a frequency of 20-Hz stimulation for 30 min. Immediately after the end of a fatigue-producing period, Group 1 received no study drug; Group 2 was infused with small-dose propofol (0.1 mg/kg initial dose plus 1.5 mg x kg(-1) x h(-1) maintenance dose); Group 3 was infused with large-dose propofol (0.1 mg/kg initial dose plus 6.0 mg x kg(-1) x h(-1) maintenance dose). We assessed diaphragmatic contractility by transdiaphragmatic pressure (Pdi). After the fatigue-producing period, in each group, Pdi at low-frequency (20-Hz) stimulation decreased from baseline values (P0.05), whereas there was no change in Pdi at high-frequency (100-Hz) stimulation. In Groups 2 and 3, with an infusion of propofol, Pdi at 20-Hz stimulation decreased from fatigued values (P0.05). Compared with Group 1, Pdi at 20-Hz stimulation decreased from fatigued values (P0.05) during propofol administration in Groups 2 and 3. The decrease in Pdi was more in Group 3 than in Group 2 (P0.05). We conclude that propofol decreases the contractility of fatigued canine diaphragm in a dose-related fashion.Propofol is a widely used IV anesthetic for the induction and maintenance of general anesthesia and sedation. It decreases, in a dose-related fashion, the contractility of fatigued diaphragm in dogs.

A sedative dose of midazolam decreases contractility of the diaphragm, but no data are available concerning the relationship between dose and diaphragmatic contractility. We studied the dose-response characteristics of midazolam for reducing the diaphragmatic contractility in dogs. Animals were divided into three groups of eight each: Group 1 received no study drug, Group 2 was infused with a sedative dose of midazolam (0.1 mg/kg initial dose plus 0.1 mg x kg(-1) x h(-1) maintenance dose), and Group 3 was infused with an anesthetic dose of midazolam (0.1 mg/kg initial dose plus 0.5 mg x kg(-1) x h(-1) maintenance dose). We assessed the diaphragmatic contractility by transdiaphragmatic pressure (Pdi). With an infusion of midazolam in Groups 2 and 3, Pdi at low-frequency (20 Hz) and high-frequency (100 Hz) stimulation decreased from the baseline values (P0.05), and the integrated electrical activity of diaphragm (Edi) at 100-Hz stimulation decreased from the baseline values, whereas Edi at 20-Hz stimulation did not change. Compared with Group 1, Pdi and Edi for each stimulus decreased during midazolam infusion in Groups 2 and 3 (P0.05). The decrease in Pdi and Edi was more in Group 3 than in Group 2 (P0.05). We conclude that midazolam decreases, in a dose-dependent manner, contractility of the diaphragm in dogs.

The effect of intravenous buprenorphine on emergence time from sevoflurane anesthesia and postoperative analgesic requirement was evaluated after otolaryngeal surgeries. Forty-five patients were randomly assigned to one of three treatment groups (n = 15 each): Control-group received saline as a control; 2 micrograms-group received buprenorphine 2 micrograms.kg-1; and 4 micrograms-group received buprenorphine 4 micrograms.kg-1, respectively. Study drug was administered intravenously at the induction of general anesthesia. Anesthesia was maintained with sevoflurane (1.5%) and nitrous oxide (66%) in oxygen. The pain score, postoperative analgesic requirement, and incidence of nausea and/or vomiting were examined. The emergence times were 16.4 +/- 3.5, 14.7 +/- 5.2, and 17.8 +/- 7.7 min [mean +/- SD], in the control-group, the 2 micrograms-group, and the 4 micrograms-group, respectively. There were no differences among the groups in term of the end-tidal sevoflurane concentration immediately before tracheal extubation. In the control-group, the 2 micrograms-group, and the 4 micrograms-group, 10, 1, and 3 patients, requested additional analgesics during the first 24 hours after surgery, respectively (control-group vs. 2 micrograms-group and 4 micrograms-group, P0.05). Nausea and vomiting occurred more frequently in the 2 micrograms-group and the 4 micrograms-group. We conclude that buprenorphine (2 or 4 micrograms.kg-1) reduced analgesic requirement during the first 24 hours after surgery without delaying emergence from sevoflurane anesthesia.

A 9-year-old boy underwent biopsy of the tumor at the external auditory meatus under general anesthesia with a laryngeal mask airway(LMA). During emergence from anesthesia, laryngospasm with marked inspiratory effort and cyanosis occurred. The LMA was removed and the patient was orotracheally intubated following vecuronium administration. In spite of controlled ventilation with 100% oxygen, oxygen saturation remained at low 90s and pink frothy sputum appeared in the tracheal tube. We suspected negative pressure pulmonary edema and treated him with mechanical ventilation with positive end-expiratory pressure. Seventeen hours later the pink frothy sputum decreased and he was extubated. Laryngospasm during emergence from anesthesia with an LMA can induce negative pressure pulmonary edema, especially in pediatric patients.

We report the anesthetic management of patients with dilated cardiomyopathy who underwent left ventricular assist device implantation (LVAD). Anesthesia was induced and maintained with midazolam and fentanyl. Transesophageal echocardiography (TEE) and a PA catheter were useful for hemodynamic monitoring and management of the patients. Furthermore, TEE is useful for the early detection of inflow of the air which is absorbed by negative pressure derived from high LVAD support pressure. On starting LVAD support, evaluation of right ventricular function and treatment for right ventricular failure were important and necessary for the patients. Added to conventional therapy using catecholamines, inhaled nitric oxide may provide a favorable effect for right ventricular failure.

To evaluate the effects of low-dose olprinone, a phosphodiesterase III inhibitor, on contractility and its mechanism in nonfatigued and fatigued diaphragm in dogs.Thirty six pentobarbitone-anesthetized dogs were studied. In Group Ia (n=6), animals without fatigue, received no study drug. In Group Ib (n=6), dogs were given a bolus injection (10 ug x kg(-1)) followed by continuous infusion (0.1 microg x kg(-1) x min(-1)) of olprinone. In Groups IIa, IIb, and IIc (n=8 each), diaphragmatic fatigue was induced by intermittent supramaximal bilateral electrophrenic stimulation at a frequency of 20-Hz applied for 30 min. After producing fatigue, Group IIa received no study drug; Group IIb was infused with olprinone (10 ug x kg(-1) loading dose plus 0.1 microg-kg(-1) min(-1) maintenance dose); Group IIc was infused with nicardipine (5 microg x kg(-1) x min(-1)) during olprinone administration. Diaphragmatic contractility was assessed by transdiaphragmatic pressure (Pdi).No difference in Pdi was observed between Groups Ia and Ib. After fatigue, in Groups IIa, IIb, and IIc, Pdi at low-frequency (20-Hz) stimulation decreased from prefatigued (baseline) values (P0.05), whereas there was no change in Pdi at high-frequency stimulation (100-Hz). In Group IIb, during olprinone administration, Pdi at both stimuli increased from fatigued values (P0.05). In Group IIc, the augmentation of Pdi to each stimulus in fatigued diaphragm by olprinone was abolished with an infusion of nicardipine.Low-dose olprinone does not affect contractility in nonfatigued diaphragm, but increases contractility in fatigued diaphragm via its effect on transmembrane calcium movement in dogs.

Hysteroscopical myomectomy has recently become popular in Japan. We present two patients who developed water intoxication and air embolism during surgery. [Case 1] Hysteroscopical myomectomy was performed under general anesthesia in a 37-yr-old woman (ASA I). Three hours after the start of the surgery, the patient's serum sodium concentration dropped to 118 mEq.l-1. She was treated with furosemide and recovered without sequelae. [Case 2] A 39-yr-old woman (ASA I) was scheduled to have hysteroscopical myomectomy under spinal and epidural anesthesia. Forty-five minutes after the start of the surgery, the patient complained of severe back pain, her blood pressure decreasing to 40 mmHg, SpO2 decreased to 80%, and ECG showed atrial fibrillation. After administration of ephedrine 5 mg, she recovered within 20 min. No abnormality was observed in echocardiogram, although some negative spots were detectable in a lung scintigraphy. She was discharged without sequelae. The hysteroscopical procedure is considered a non-invasive surgery, but the cases presented here emphasize the necessity for close attention to complications, especially pulmonary embolism.

This study was undertaken to examine the effect of xenon on diaphragmatic contractility in pentobarbitone- anesthetized, mechanically ventilated dogs.Twenty-one dogs were randomly allocated to three groups (n=7 of each): Group I received oxygen 100%; Group II received xenon 30% in oxygen; Group III received xenon 60% in oxygen. Diaphragmatic contractility was assessed by measuring transdiaphragmatic pressure (Pdi) generated during supramaximal stimulation of phrenic nerves at the neck at low-frequency (20-Hz) and high-frequency (100-Hz) stimulation, after maintaining 60 min of stable condition.With inhalation of xenon at two different concentration (30% and 60%), no changes were observed in Pdi at either concentration. There was no difference in Pdi among the three groups.Increasing the concentration of xenon to 60% has no effect on diaphragmatic contractility in dogs. This suggests that xenon may be used safely as an anesthetic with respect to respiratory muscle function.

This study was designed to evaluate the effects of diazepam and clonidine orally given preoperatively on cardiovascular responses to tracheal extubation in children. Fifty children, ASA physical status I, aged 4-10 years, undergoing minor elective surgery (inguinal hernia, phimosis) received orally, in a randomized, double-blind manner, diazepam 0.4 mg.kg-1 or clonidine 4 microgram.kg-1 (n=25 of each). These drugs were administered 105 min before an inhalational induction of anaesthesia. The same standard general anaesthetic technique was employed throughout. The maximum changes in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were less in patients who had received clonidine than in those who had received diazepam (HR, 12 vs 24; SBP, 14 vs 26; DBP, 9 vs 16; mean, P0.05). In conclusion, compared to diazepam given orally, pretreatment with oral clonidine attenuates haemodynamic changes associated with tracheal extubation in children.

A history of motion sickness is one of the patient-related factors associated with postoperative emesis. This prospective, randomized, double-blind, placebo-controlled study was undertaken to assess the efficacy of granisetron, a selective 5-hydroxytryptamine type 3 receptor antagonist, for preventing postoperative vomiting after tonsillectomy in 120 children with (n = 60) and without (n = 60) a history of motion sickness. Patients received a single dose of granisetron (40 micrograms.kg-1) or placebo (saline) (n = 30 of each) intravenously after an inhalation induction of anaesthesia. A complete response, defined as no vomiting, no retching and no need for another rescue medication, during the first 24 h after anaesthesia was 77% and 13% in patients with a history of motion sickness who had received granisetron or placebo, respectively; the corresponding incidence was 83% and 40% in those without it (P0.05; chi 2 test with Yates' continuity correction). No clinically serious adverse effects due to the study drug were observed in any of the groups. In conclusion, prophylactic antiemetic therapy with granisetron is effective for preventing postoperative emesis in children with a history of motion sickness as well as in those without it.

A 23-year-old patient with dilated cardio myopathy (DCM) was scheduled for a cesarean section. We inserted an epidural catheter at the L 2/3 interspace and injected 1.5% lidocaine 6 ml with epinephrine 30 micro g and fentanyl 50 micro g. The analgesic level 15 minutes after injection was achieved up to the eighth thoracic dermatome. Dopamin 5 micro g.kg-1.min-1 was infused simultaneously. Analgesia was sufficient for the surgery, and heart rate and blood pressure were stable throughout the operation. The infant's apgar scores were 9 and 10. Epidural anesthesia is one of the options for cesarean section in pregnant women with DCM.

Hypertensive patients exhibit exaggerated cardiovascular responses to tracheal extubation. This study was undertaken to compare the efficacy of combined diltiazem and lidocaine with each drug alone in suppressing the hemodynamic changes during tracheal extubation.Sixty hypertensive patients (ASA II), defined as systolic blood pressure160 mmHg and/or diastolic blood pressure95 mmHg (WHO), undergoing elective orthopedic surgery received, in a randomized, double-blind manner, 0.2 mg x kg(-1) diltiazem, 1.0 mg x kg(-1) lidocaine, or 0.2 mg x kg(-1) diltiazem plus 1.0 mg x kg(-1) lidocaine (n=20 of each) i.v. before tracheal extubation. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and after tracheal extubation.Hemodynamic changes during tracheal extubation were less in patients receiving diltiazem plus lidocaine than in those receiving diltiazem or lidocaine as a sole medicine (RPP; 10322 +/- 1674 (combined) vs 11532 +/- 1802 (diltiazem), 15388 +/- 2050 (lidocaine), mean +/- SD, P0.05).Combined diltiazem and lidocaine is more effective prophylaxis than diltiazem or lidocaine alone for attenuating the cardiovascular responses to tracheal extubation and emergence from anesthesia in hypertensive patients.

To compare the efficacy of ramosetron with granisetron for the prevention of postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy.In a randomized, double-blind study, 80 female inpatients received 3 mg granisetron or 0.3 mg ramosetron i.v. (n=40 of each) at the completion of surgery The standardized anesthetic included isoflurane and nitrous oxide in oxygen.Complete response, defined as no PONV, during the first 24 hr (0-24 hr) after anesthesia was 85% with granisetron and 93% with ramosetron, respectively (P=0.241); the corresponding incidence during the next 24 hr (24-48 hr) after anesthesia was 63% and 90% (P=0.004). No clinically important adverse events due to the study drug were observed in any of the groups.Ramosetron was more effective than granisetron for prevention of PONV during 0-48 hr after anesthesia for laparoscopic cholecystectomy.

This study was undertaken to compare the efficacy of granisetron plus droperidol with each antiemetic alone for the prevention of vomiting after paediatric strabismus surgery. In a prospective, randomized, double-blinded trial, 120 ASA physical status I children, aged 4-10 years, received granisetron 40 microg.kg- 1, droperidol 50 microg.kg- 1, granisetron 40 microg.kg- 1 plus droperidol 50 microg.kg- 1 (n=40 of each) intravenously after an inhalation induction of anaesthesia. A complete response, defined as no vomiting, no retching and no need for another rescue antiemetic medication, during 0-3 h after anaesthesia was 80% with granisetron, 45% with droperidol and 98% with granisetron plus droperidol, respectively; the corresponding incidence during 3-24 h after anaesthesia was 78%, 38% and 98% (P0.05; overall chi-squared test with Yates continuity correction). No clinically important adverse events were observed in any of the groups. In conclusion, a combination of granisetron and droperidol was more effective than granisetron or droperidol as a sole antiemetic for the prevention of postoperative vomiting in children undergoing strabismus repair.

The efficacy of granisetron, droperidol and metoclopramide for the prevention of postoperative nausea and vomiting in female patients undergoing middle ear surgery was compared. In a randomised, double-blind study, 180 patients received granisetron 40 micrograms.kg-1, droperidol 20 micrograms.kg-1 or metoclopramide 0.2 mg.kg-1 given intravenously immediately before induction of anaesthesia (n = 60 for each). A standardised general anaesthetic technique was employed throughout. A complete response, defined as no postoperative nausea and vomiting and no need for another rescue anti-emetic, during the first 3 h after anaesthesia was achieved in 83%, 58% and 55% of patients who had received granisetron, droperidol and metoclopramide, respectively. The corresponding incidence during the next 21 h after anaesthesia was 85%, 54% and 47% (p0.05). No clinically important adverse effects were observed in any of the groups. We conclude that prophylactic therapy with granisetron is superior to droperidol or metoclopramide in the prevention of postoperative nausea and vomiting after middle ear surgery.

We report two cases of refractory pain in a spinal disease. One case was a 60-year-old male who presented intractable pain in bilateral upper extremities after anterior fusion (C5/6, 6/7) for cervical spondylosis. The other was a 63-year-old female who also had intractable pain in the left anterio-lateral chest wall with no remarkable past history. Both cases were refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) or minor tranquilizer or local anesthesia with bupivacaine. However, their pain was significantly relieved by the intravenous administration of a test dose (5mg) of ketamine which is a noncompetitive blocker of N-methyl-D-aspartate (NMDA) receptors. As for case 1, the effect of the injection of the test dose lasted, so continuing infusion therapy of ketamine was cancelled. In case 2, recurrence of the pain was recognized gradually. She underwent continuing infusion therapy of 2mg/kg of ketamine, and it brought about continued pain relief. We conclude that ketamine infusion therapy should also be considered for therapy of refractory neuralgia in spinal disease.

Hypertensive patients are prone to haemodynamic changes after laryngoscopy and tracheal intubation. This study was undertaken to compare the efficacy of a combination of diltiazem and lidocaine with that of each drug alone for suppressing the cardiovascular responses to tracheal intubation.Sixty hypertensive patients (ASA II), defined as systolic blood pressure160 mmHg and/or diastolic blood pressure95 mmHg (World Health Organization), undergoing elective surgery received, in a randomized, double-blind manner, 0.3 mg.kg-1 diltiazem, 1.5 mg.kg-1 lidocaine, or 0.3 mg.kg-1 diltiazem plus 1.5 mg.kg-1 lidocaine i.v. (n = 20 of each) before the initiation of laryngoscopy. Anaesthesia was induced with 5 mg.kg-1 thiopentone i.v., and tracheal intubation was facilitated with 2 mg.kg-1 succinylcholine i.v. after precurarization with 0.02 mg.kg-1 vecuronium i.v. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and at immediate, 1, 2, 3, 5 and 10 min after tracheal intubation.The inhibitory effects of diltiazem-lidocaine combination on cardiovascular responses to tracheal intubation was greater than those of diltiazem or lidocaine as a sole medicine (RPP; 10,602 +/- 1448 (combination) vs 11,787 +/- 1345 (diltiazem), 15,428 +/- 1756 (lidocaine), mean +/- SD, P0.05).Prophylactic therapy with diltiazem-lidocaine combination is more effective than diltiazem or lidocaine alone for attenuating the cardiovascular changes associated with tracheal intubation in hypertensive patients.

We used a new method for central venous (CV) access via the distal femoral vein using ultrasound guidance in two cases. In the first case, because of multiple catheter punctures for hemodialysis previously, femoral catheter placement was impossible using a standard landmark technique. In the second case of laryngoplasty, it was also impossible to place a CV catheter at usual groin sites because of extensive mycosis. In these two cases, we attempted CV catheterization via the distal femoral vein at the femur (10 cm from the inguinal ligament) by using ultrasound guidance. In both cases the catheter placement was easy and took a short time. No complication due to puncture and catheterization was observed. CV access via the femoral vein in the groin has been the first-choice for the patients undergoing neuro- or neck-surgery. However, the femoral CV catheters at inguinal site has been associated with higher incidence of catheter infection than the subclavian or internal jugular vein. These methods have a potential for decrease in catheter infection rate. These two case reports suggest that the CV catheterization at distal femoral site by ultrasound-guidance is useful as a new method of CV access.

This study was undertaken to determine the minimum effective dose of granisetron, a selective 5-hydroxytryptamine type 3 receptor antagonist, for the prevention of post-operative nausea and vomiting (PONV) in female patients undergoing elective laparoscopic cholecystectomy. In randomized, placebo-controlled, double-blind study, 120 women were assigned to receive either placebo (saline) or granisetron at three different doses (20 micrograms kg-1, 40 micrograms kg-1 or 80 micrograms kg-1) intravenously immediately before the induction of anaesthesia. All patients received standardized anaesthesia consisting of isoflurane and nitrous oxide in oxygen. The incidence of PONV during the first 24 hours after anaesthesia was 43, 40, 13 and 13% after administration of placebo and granisetron 20 micrograms kg-1, 40 micrograms kg-1 and 80 micrograms kg-1, respectively (P0.05, overall Fisher's exact probability test). Adverse effects post-operatively were not different among the groups. In conclusion, granisetron 40 micrograms kg-1 is the minimum effective dose in the prevention of PONV after laparoscopic cholecystectomy.

We report a clinical experience of continuous intra-arterial blood gas monitoring (PARATREND 7:P 7) during bronchopulmonary lavage. A 47-year-old, 86-kg male was suffering from myelodysplastic syndrome associated with alveolar proteinosis. Bronchopulmonary lavage was scheduled to alleviate the symptom. P 7 and a continuous cardiac output monitor were used with an EKG monitor, a pulse oximeter, and a esophageal stethoscope. Anesthesia was maintained using sevoflurane and fentanyl. The patient's trachea was intubated with a double-lumen endobronchial tube (39-F Broncho-cath; Mallinckrodt, Ireland). After denitrogenation and degassing, warmed isotonic saline was infused into his left lung. The volume chosen was 2,200 ml which approximated the sum of the patient's functional residual capacity and tidal volume. The lowest point of PO2 appeared at the point 'degassed'. P 7 showed a consecutive rise of PO2 associated with infusion of large volume of saline. Although the response to change in PO2 of P 7 is slower than pulse oximeter, frequent blood sampling can be avoided. We think that P 7 with pulse oximeter are useful for the safe management of pulmonary lung lavage.

This prospective, randomized, double-blinded study evaluated the antiemetic efficacy of granisetron and droperidol in 80 ASA physical status I children, aged 4-10 years, undergoing strabismus surgery or tonsillectomy with or without adenoidectomy. After anaesthetic induction, the patients received either granisetron (40 micrograms.kg-1, n = 40) or droperidol (50 micrograms.kg-1, n = 40) intravenously. The incidence of vomiting during the first 24h after anaesthesia was 15% and 38% after administering granisetron and droperidol, respectively (P = 0.02). The requirement for rescue antiemetic therapy for the treatment of two or more episodes of vomiting was 0% with granisetron and 18% with droperidol (P = 0.001). In conclusion, granisetron was superior to droperidol in reducing the incidence and frequency of postoperative vomiting in paediatric patients.

This study evaluates the prophylactic anti-emetic efficacy of granisetron, droperidol and metoclopramide, for the prevention of post-operative nausea and vomiting in female patients undergoing elective laparoscopic cholecystectomy. The patients were randomly assigned to one of four groups (n = 30 for each group): granisetron 3 mg, droperidol 1.25 mg, metoclopramide 10 mg and placebo (saline). These medications were given immediately before the induction of anaesthesia. During the first 24 h after anaesthesia, the incidence of post-operative nausea and vomiting was 13, 30, 33 and 37% after administration of granisetron, droperidol, metoclopramide and placebo, respectively (P0.05, overall Fisher's exact probability test). No clinically important adverse effects were observed in either group. Our results suggest that granisetron is a better anti-emetic than droperidol or metoclopramide for the prevention of post-operative nausea and vomiting after laparoscopic cholecystectomy when compared with a placebo.

A high incidence of postoperative nausea and vomiting (PONV) has been noted in patients with a history of postoperative emesis. This study was undertaken to compare the efficacy of granisetron, droperidol and metoclopramide, in the prevention of PONV in such patients undergoing general anaesthesia for major gynaecological surgery.In a randomised, double-blind study, 90 female patients received 2.5 mg granisetron, 1.25 mg droperidol or 10 mg metoclopramide (n = 30 of each) i.v. immediately before induction of anaesthesia. The same standard general anaesthetic technique, which consisted of isoflurane in nitrous oxide and oxygen, was used. Nausea, vomiting and safety assessments were performed continuously during the first 24 hr after anaesthesia.The incidence of PONV was 20% with granisetron, 57% with droperidol and 60% with metoclopramide (P0.05; overall Fisher's exact probability test). No clinically adverse events were observed in any group.Granisetron is more effective than droperidol or metoclopramide in preventing PONV in female patients with a history of postoperative emesis.

This study was designed to investigate the cardiovascular effects related to tracheal extubation or laryngeal mask airway (LMA) removal in children.Sixty children, ASA physical status 1, 4-10 yr of age, undergoing minor elective surgery (inguinal hernia and phimosis) were allocated randomly to have their surgery performed with endotracheal intubation (Group ET, n = 30) or LMA (Group LMA, n = 30) and were studied for cardiovascular responses related to extubation or LMA removal. Changes in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured before and 1, 2, 3, 5, and 10 min after tracheal extubation or LMA removal when the patients were awake.The maximal changes in HR, SBP and DBP were less in Group LMA than in Group ET during the observation period (HR; 12 vs 26, SBP; 14 vs 28, DBP; 9 vs 13, median, P0.05).Laryngeal mask airway removal elicited less haemodynamic change than tracheal extubation in paediatric patients.

A 37-year-old parturient with severe preeclampsia accompanied by pulmonary edema underwent emergency cesarean section. Pulmonary artery (PA) catheter inserted while the patient was awake revealed hyperdynamic state with increased cardiac index and preload, and decreased systemic vascular resistance. Epidural anesthesia and analgesia were provided with a satisfactory outcome. Monitoring of PA pressure and cardiac index was continued postoperatively in ICU for fluid management. We conclude that preoperative PA catheterization provides useful hemodynamic information in severe preeclamptic patients associated with persistent oliguria, pulmonary edema and hyperdynamic state.

This study was undertaken to evaluate the haemodynamic changes of tracheal extubation or removal of a laryngeal mask airway (LMA) in normotensive and hypertensive patients.In a randomized trial of normotensive and hypertensive patients (n = 40 of each), tracheal extubation or LMA removal was performed. Changes in heart rate (HR), mean arterial pressure (MAP) and rate-pressure product (RPP) were measured before and 1, 2, 3, 5, and 10 min after tracheal extubation or LMA removal.In normotensive patients, HR, MAP and RPP increased following tracheal extubation or LMA removal, and remained elevated for a maximum three minutes (P0.05). In hypertensive patients, the haemodynamic increases in response to extubation or LMA removal were observed for up to five minutes (P0.05). The immediate cardiovascular responses to extubation were greater than those related to LMA removal in both normotensive and hypertensive patients (normotensive: HR; 95 +/- 14 vs 81 +/- 11, MAP; 124 +/- 18 vs 106 +/- 10, RPP; 14,951 +/- 2720 vs 10,654 +/- 1898, hypertensive: HR 105 +/- 10 vs 87 +/- 13, MAP; 146 +/- 17 vs 119 +/- 12, RPP; 20,492 +/- 1674 vs 12,862 +/- 2115, mean +/- SD, P0.05). Following extubation or LMA removal, these haemodynamic variables increased more markedly in hypertensive patients than in normotensive patients (P0.05).Removal of LMA is associated with less cardiovascular change than tracheal extubation in both normotensive and hypertensive patients.

We have retrospectively analyzed twelve pregnancies in nine patients with intracranial arteriovenous malformation (AVM) managed at our hospital from 1984 to 1995. Following radical excision of AVM before or during pregnancy in 6 cases, transvaginal deliveries were performed without untoward sequelae. In three of five patients who received non-curative treatments, labor analgesia was provided using epidural local anesthetics. One patient who presented with ruptured AVM followed by medical therapy, elective cesarean section was performed under spinal anesthesia with a favorable outcome. Anesthesia courses in two patients for the resection of ruptured AVM during pregnancy were uneventful under enflurane and nitrous oxide anesthesia, or balanced anesthesia using fentanyl and nitrous oxide in oxygen. Simultaneous cesarean section craniotomy was not performed at our hospital.

To assess the degree of residual neuromuscular blockade, double burst stimulation (DBS) is commonly applied in the clinical setting. However, fades in response to DBS3,3 can rarely be identified manually when train-of-four (TOF) ratios areor = 0.70, and, in contrast, fades in response to DBS3,2 are felt manually in an undesirably high proportion of cases, even at TOF ratios greater than 0.7. We investigated whether a new monitoring method, modified DBS, would be useful to determine an adequate degree of recovery from neuromuscular blockade. For modified DBS, two burst stimuli were applied at an interval of 750 ms. The first stimulation in the modified DBS consisted of two stimuli of 0.3 ms duration at 50 Hz and the second of two stimuli of 0.2 ms duration at 50 Hz.Forty-five adult patients undergoing elective nitrous oxide-oxygen-isoflurane anesthesia were randomly divided into one of three groups: DBS3,3 group (n = 15), DBS3,2 group (n = 15), or modified DBS group (n = 15). During recovery from vecuronium-induced neuromuscular blockade, on both forearms, DBS3,3, DBS3,2, and modified DBS were delivered in the DBS3,3 group, DBS3,2 group, and modified DBS group, respectively. One hand and forearm (fixed arm) were immobilized to quantify the degree of neuromuscular blockade mechanically, and the contralateral arm (free arm) was unrestrained. An observer determined tactiley on the free arm the presence or absence of fade in response to the three DBS patterns.Probabilities of detection of fade in response to the DBS3,3 were 67% (TOF ratio of 0.51-0.60), 40% (0.61-0.70), 19% (0.71-0.80), 5% (0.81-0.90), and 0% (0.91-1.00). Those to the DBS3,2 were 95% (0.51-0.60), 93% (0.61-0.70), 83% (0.71-0.80), 65% (0.81-0.90), and 38% (0.91-1.00). Those to modified DBS were 90% (0.51-0.60), 86% (0.61-0.70), 65% (0.71-0.80), 25% (0.81-0.90), and 3% (0.91-1.00). Those modified DBS was more sensitive in diagnosing residual neuromuscular blockade than DBS3,3 at the TOF ratio of 0.51-0.90, but was less sensitive than DBS3,2 at the TOF ratio of 0.81-1.00 (P0.05).Our results indicate that the modified DBS may be a useful stimulation pattern to diagnose the adequacy of recovery from neuromuscular blockade.

A new stimulation pattern for evaluation of intense neuromuscular block (post-tetanic burst (PTB)) was compared with post-tetanic twitch (PTT) during spontaneous recovery from vecuronium-induced neuromuscular block. Thirty adult patients were allocated to two equal groups and we measured times from administration of vecuronium 0.1 mg kg-1 to return of PTB and PTT responses, and evoked responses to PTB and PTT stimuli. For PTB stimulation, a 50-Hz tetanus was applied at 50 mA for 5 s, and after a pause of 3 s, a 50-Hz burst stimulation was applied, consisting of three impulses at 50 mA. PTB stimuli were delivered every 5 min. Similarly, PTT consisted of a tetanus, a 3-s pause and one single twitch stimulation repeated every 5 min. Time to return of the PTB response was significantly shorter than that of PTT (mean 23.7 (SD 7.9) compared with 30.7 (7.0) min) (P = 0.0160), although evoked responses to PTB did not differ significantly from those of PTT throughout recovery from vecuronium-induced neuromuscular block. This study suggested that PTB was more sensitive in evaluating intense neuromuscular block than PTT.

This study was performed to examine the hypothesis that PSV with PEEP compared to spontaneous breathing with a circle anesthesia system may have beneficial effects on gas exchange and work of breathing during inhalational anesthesia. Nine patients (age; 58 +/- 20 yr) scheduled to receive general anesthesia for orthopedic (n = 3) or ENT (n = 6) surgery were randomly assigned in a triple cross-over manner to breathe with a standard anesthesia circle system, 5 cmH2O PSV, and 5 cm H2O PSV above 5 cmH2O PEEP. General anesthesia was induced with thiamylal (5 mg.kg-1) and succinylcholine (1 mg.kg-1), followed by tracheal intubation. General inhalation anesthesia was maintained with 1% isoflurane and nitrous oxide in 40% oxygen. Patients were permitted to breathe spontaneously. A BiPAP-S Ventilatory Support System was connected to a standard anesthesia machine instead of a reservoir bag to deliver PSV or PSV with PEEP. Respiratory parameters were measured with a C-P 100 Pulmonary Monitor. After breathing for 20 minutes with the assigned mode, measurements and blood gas sampling were performed. Statistical analysis was performed with ANOVA. There were no statistical differences in PaO2 within the three groups (table). PaCO2 was lower during PSV+PEEP, but the difference was not significant. This level of PSV or PSV with PEEP may have little beneficial effects on gas exchange in our study condition. The mean WOBp was smaller in the PSV with PEEP group but the difference was not statistically significant.

The radiopacity of 12 VL-cured composite resins was determined with reference to an aluminum step-wedge. Two anterior composites were radiolucent while two anterior and one anterior/posterior composites exhibited the radiopacity equal to, or slightly greater than, that of human enamel. Three posterior and one inlay composites possessed the radiopacity equivalent to, or in tiny excess of, that of human enamel. Three posterior composites had the radiopacity, fairly exceeding that of human enamel. Chemical analyses of the filler particles were carried out with SEM/EDX. It became evident that radiopaque fillers contained at least one radiopaque oxide component such as BaO, ZrO2 and Yb2O3 with varying concentrations. In general, the radiopacity of the composite resin was linearly proportional to the amount of the radiopaque oxide in the filler. It was suggested that ZrO2 was radiopacifier equivalent to, or even stronger than, BaO.

We anesthetized a patient for esophageal resection in a right lateral decubitus position, because of his right pleural adhesion after lobectomy for tuberculosis. Although hypoxemia was expected on left lung compression during the surgery, oxygenation was not compromised. A good ventilation/perfusion relationship might have been maintained in both the right and left lungs during the procedure.

A rare case of spinal cord injury at C3 level associated with Arnold-Chiari malformation is reported. A 33 year old male was admitted with a complaint of walking difficulty. MRI revealed cerebellar herniation, and a plain X-ray showed spinous process adhesion of C2-3 and slight scoliosis. Percent vital capacity was reduced to 69%, and blood cell count showed a slight anemia. The patient was anesthetized for an orthopedic surgery with pethidine 70 mg, thiamylal 200 mg, 60% nitrous oxide, 40% oxide, and 0.5-1.2% isoflurane. There was a mild decrease in arterial blood pressure during surgical procedures, but this could be easily treated by fluid therapy, and there was no episode of autonomic hyperreflexia. Postoperative course of the patient was uneventful, except a transient pneumonia and urinary tract infection. The key in the anesthetic management of Arnold-Chiari malformation with spinal cord injury is the control of intracranial pressure, care for respiratory dysfunction and the prevention of infection as well as autonomic hyperreflexia.

Effects of highly decreased cardiac output on the development and recovery of diaphragmatic fatigue were studied in dogs. The fatigue was induced by supramaximal electrical stimulation (20 Hz) of phrenic nerves for 30 minutes. Cardiac output was reduced during this period to 30% of control value by mechanically obstructing inferior vena cava with a balloon in animals with lowered cardiac output group (lowered Qt group). Cardiac output was maintained at normal value throughout the experiment in animals of the other group (control group). The animals were observed for recovery for 60 minutes after induction of the fatigue. The standardized transdiaphragmatic pressure (Pdi/Pdi 100) and integrated electromyographic activity (Edi/Edi 100) elicited by electrical test stimuli (20, 100 Hz) were significantly lower in lowered Qt group (P less than 0.01) during entire fatigue and recovery period. The decrease of Pdi/Pdi 100 and Edi/Edi 100 at high frequency test stimuli (100 Hz) was observed only in lowered Qt group. These results suggest that when cardiac output is severely decreased the diaphragm is more susceptible to fatigue, and that this may be caused by a failure of neuromuscular junction as well as by an impaired excitation-contraction coupling.

The role of impairment of neuromuscular transmission in fatigued canine diaphragm was investigated by comparing the function of fatigued diaphragm with that of neuromuscular junction (NMJ)-blocked diaphragm. Diaphragmatic fatigue was produced by intermittent supramaximal stimulation of bilateral phrenic nerves. Partial NMJ blockade was obtained by vecuronium bromide administered intravenously. During control study, no fade was observed either in integrated diaphragmatic electric activity (Edi) or transdiaphragmatic pressure (Pdi). In fatigued diaphragm, Edi generated by 100 Hz showed a remarkable fade. The fade was prominent in high frequency fatigue. In NMJ-blocked diaphragm, fade was observed in Pdi as well as in Edi produced by 100 Hz. The fade of Edi by 100 Hz was prominent. In low frequency fatigue, both Pdi and Edi produced by 20 Hz test stimulation were significantly lower than control values. These results show that in addition to impairment of excitation-contraction coupling, neuromuscular blockade is involved, at least in part, in low frequency diaphragmatic fatigue.