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BACKGROUND: Few studies (in other countries than the US) have reported on the efficacy and safety of dexmedetomidine for sedation of patients undergoing surgical or medical procedures under local anesthesia without intubation outside the intensive care unit. We performed a randomized, double-blind study in Japan. METHODS: Adult patients were randomly allocated to receive placebo, dexmedetomidine 0.5 μg/kg (DEX 0.5 group), or dexmedetomidine 1.0 μg/kg (DEX 1.0 group) over 10 min. Then, both dexmedetomidine groups received dexmedetomidine 0.2–0.7 μg/kg/h for maintaining an Observer’s Assessment of Alertness/Sedation Scale (OAA/S) score of ≤ 4; however, propofol was administered to rescue patients whose score exceeded this value. The primary endpoint was the percentage of patients who did not require rescue propofol to achieve and maintain an OAA/S score of ≤ 4. RESULTS: In total, 162 patients were included in the placebo (n = 53), DEX 0.5 (n = 53), and DEX 1.0 (n = 56) groups. Propofol was not required in significantly more patients in the dexmedetomidine 0.5 and 1.0 μg/kg groups (52.8% and 57.1%, respectively) compared with the placebo group (1.9%) (P < 0.001 for both). Common adverse events were protocol-defined hypotension, respiratory depression and bradycardia. The incidence of bradycardia was significantly higher in the DEX 0.5 (26.4%) and DEX 1.0 (30.4%) groups than in the placebo group (9.4%) (P = 0.041 and P = 0.008, respectively). CONCLUSION: We concluded that a loading dose of 0.5 or 1.0 μg/kg dexmedetomidine followed by infusion at a rate of 0.2–0.7 μg/kg/h provided effective and well-tolerated sedation in patients undergoing surgical or medical procedures under local anesthesia without intubation. Clinical trials.gov identifier: NCT01438931

BACKGROUND: Only a few studies have been reported on the use of dexmedetomidine for sedating surgical patients requiring epidural or spinal anesthesia. We conducted a randomized, double-blind, placebo-controlled, parallel-group study at 12 hospitals in Japan. METHODS: Adult patients were randomly allocated to receive an intravenous administration of placebo or dexmedetomidine at 0.067, 0.25, 0.5 or 1.0 µg/kg over 10 min after epidural or spinal anesthesia. All dexmedetomidine groups received dexmedetomidine 0.2–0.7 µg/kg/h to maintain an Observer’s Assessment of Alertness/Sedation Scale (OAA/S) score of ≤ 4; however, propofol was administered to rescue patients who exceeded this score. Surgery was then started 15 min after study drug infusion in patients with OAA/S score of ≤ 4. The primary endpoint was the percentage of patients not requiring rescue propofol to achieve and maintain an OAA/S score of ≤ 4. RESULTS: Of the 120 enrolled and randomized patients, 119 were treated the study: 22 received placebo and 97 received dexmedetomidine (23–25 patients per dose). Significantly more patients did not require propofol in the dexmedetomidine 0.5 and 1.0 µg/kg groups (68.0% and 80.0%, respectively) compared to the placebo group (22.7%) (P = 0.003 and P < 0.001, respectively). Common adverse events (AEs) were protocol-defined respiratory depression, bradycardia and hypotension. There was no significant difference in the incidence of AEs between the dexmedetomidine and the placebo groups. CONCLUSION: We concluded that loading doses of 0.5 and 1.0 µg/kg dexmedetomidine, followed by an infusion at a rate of 0.2–0.7 µg/kg/h, provide effective and well-tolerated sedation for surgical patients during epidural or spinal anesthesia. Clinical trials.gov identifier: NCT01438957

AIM Direct-acting antivirals (DAAs) are currently available even for patients with decompensated cirrhosis. Reportedly, hepatic functional reserve improved in the short term after achievement of sustained virologic response (SVR). We aimed to clarify the outcomes after achievement of SVR in patients with decompensated cirrhosis who were treated by DAAs in real-world clinical practice. METHODS A prospective, multicenter study of 12-week sofosbuvir/velpatasvir was conducted in 86 patients with decompensated cirrhosis, who were evaluated for 48 weeks post-treatment. RESULTS The cohort included 8 patients with Child-Pugh class A, 56 with B, and 22 with C. The proportion of Child-Pugh class A patients increased from 9.1% at baseline to 44.1% at 48 weeks post-treatment, while that of class B and C patients decreased from 66.2% to 35.1% and from 24.7% to 14.3%, respectively. Among the patients with Child-Pugh class B and C, univariate analysis identified low total bilirubin, Child-Pugh score, Child-Pugh class B, ALBI score, and high serum albumin as factors associated with improvement to Child-Pugh class A. The optimal cut-off value of the factors for predicting improvement to Child-Pugh class A were 1.4 mg/dL for total bilirubin, 2.9 g/dL for serum albumin, 8 points for Child-Pugh score, and -1.88 for ALBI score. CONCLUSION Achievement of SVR with sofosbuvir/velpatasvir improved the liver functional reserve at 12 weeks post-treatment and maintained the stable effects until 48 weeks post-treatment in patients with decompensated cirrhosis. Specifically, the patients with less advanced conditions had the likelihood of improving to Child-Pugh class A at 48 weeks post-treatment. This article is protected by copyright. All rights reserved.

This trial was conducted to confirm the non-inferiority of remimazolam versus propofol in the induction and maintenance of general anesthesia in surgical patients. Surgical patients (n = 375) were randomized to remimazolam started at 6 or 12 mg/kg/h by continuous intravenous (IV) infusion until the loss of consciousness (LoC), followed by 1 mg/kg/h to be adjusted as appropriate until the end of surgery or IV propofol administered as a slow bolus of 2.0–2.5 mg/kg until LoC followed by 4–10 mg/kg/h until the end of surgery. Efficacy was measured via the combined primary endpoint of no intraoperative awakening/recall, no need for rescue sedatives, and no body movements. Adverse events and adverse drug reactions (ADRs) were monitored for safety. Efficacy rates were 100% in all treatment groups, and the non-inferiority of remimazolam was demonstrated [95% confidence interval (− 0.0487; 0.0250)]. The time to LoC was longer in the remimazolam 6 (p

Pressure-sensitive-paint (PSP) measurement was conducted for unsteady phenomena at various frequencies up to the order of kHz in low-speed flow to evaluate measurement accuracy of PSP. Pressure fluctuations on the floor surface induced by the Karman vortex were measured by PSP and unsteady pressure transducer. The dominant frequency of the pressure fluctuations is varied from 0.15 to 1.7 kHz by changing the size of the square cylinder. While regions with large pressure fluctuations could be visualized by calculating root mean square of pressure fluctuations from PSP images, the values significantly differed from those measured by pressure transducer. By applying Fast Fourier Transform (FFT), the power spectral density (PSD) at peak frequencies could be obtained within an error of 20%. Singular-value decomposition (SVD) yields a remarkable improvement in signal-to-noise ratio. However, amplitude of pressure fluctuations is changed depending on the way how to select modes. Three mode-selection methods for SVD filtering/reconstruction analysis are proposed in this study which show good improvement compared with convection method and are proved capable of extracting characteristic behaviors of the flow phenomena even below the noise floor.

AIM: Cooling the pharynx and upper oesophagus would be more advantageous for rapid induction of therapeutic hypothermia since the carotid arteries run in their vicinity. The aim of this study was to determine the effects of pharyngeal cooling on brain temperature and the safety and feasibility for patients under resuscitation. METHODS: Witnessed non-traumatic cardiac arrest patients (n=108) were randomized to receive standard care with (n=53) or without pharyngeal cooling (n=55). In the emergency room, pharyngeal cooling was initiated before or shortly after return of spontaneous circulation by perfusing physiological saline (5 °C) into a pharyngeal cuff for 120 min. RESULTS: There was a significant decrease in tympanic temperature at 40 min after arrival (P=0.02) with a maximum difference between the groups at 120 min (32.9 ± 1.2°C, pharyngeal cooling group vs. 34.1 ± 1.3°C, control group; P

Neuroprotective effects of esmolol in laboratory and clinical settings have been reported. The present study was designed to quantitatively evaluate the neuroprotective effects of esmolol using logistic regression curves and extracellular potentials.In 42 gerbils, bilateral occlusion of common carotid arteries was performed for 3, 5, or 7 minutes (n=7 in each group). In treated animals, esmolol (200 µg/kg/min) was administered for 90 minutes, 30 minutes before the onset of ischemia. Direct current potentials were measured in the bilateral CA1 regions, in which histologic evaluation was performed 5 days later. Relations of neuronal damage with ischemic duration and duration of ischemic depolarization were determined using logistic regression curves.There was no significant difference in onset time between the 2 groups (the control group vs. the esmolol group: 1.65±0.46 vs. 1.68±0.45 min, P=0.76), and significant differences in durations of ischemic depolarization were not observed with any ischemic duration. However, logistic regression curves indicated that esmolol has a neuroprotective effect from 2.95 to 7.66 minutes of ischemic depolarization (P0.05), and esmolol prolonged the duration of ischemic depolarization causing 50% neuronal damage from 4.97 to 6.34 minutes (P0.05). Logistic regression curves also indicated that esmolol has a neuroprotective effect from 3.77 to 7.74 minutes of ischemic duration (P0.05), and esmolol prolonged the ischemic duration causing 50% neuronal damage from 4.26 to 4.91 minutes (P0.05).Esmolol has neuroprotective effects in the acute phase of ischemia by a mechanism other than shortening the duration of ischemic depolarization.

Purpose: Delirium is a common complication in postoperative critically ill patients. Although abnormal melatonin metabolism is thought to be one of the mechanisms of delirium, there have been few studies in which the association between alteration of perioperative plasma melatonin concentration and postoperative delirium was assessed. Materials: We conducted a prospective observational study to assess the association of perioperative alteration of plasma melatonin concentration with delirium in 40 postoperative patients who required intensive care for more than 48 hours. We diagnosed postoperative delirium using Confusion Assessment Method for the intensive care unit and measured melatonin concentration 4 times (before the operation as the preoperative value, 1 hour after the operation, postoperative day 1, and postoperative day 2). Results: Postoperative delirium occurred in 13 (33%) of the patients. Although there was no significant difference in preoperative melatonin concentration, Delta melatonin concentration at 1 hour after the operation was significantly lower in patients with delirium than in those without delirium (-1.1 vs 0 pg/mL, P = .036). After adjustment of relevant confounders, Delta melatonin concentration was independently associated with risk of delirium (odds ratio, 0.50; P = .047). Conclusions: Delta melatonin concentration at 1 hour after the operation has a significant independent association with risk of postoperative delirium. (c) 2013 Elsevier Inc. All rights reserved.

Rats were subjected to 90 min of focal ischemia by occluding the left middle cerebral and both common carotid arteries. The dynamic changes in the formation of brain ischemic areas were analyzed by measuring the direct current (DC) potential and reduced nicotinamide adenine dinucleotide (NADH) fluorescence with ultraviolet irradiation. In the lidocaine group (n = 10), 30 min before ischemia, an intravenous bolus (1.5 mg/kg) of lidocaine was administered, followed by a continuous infusion (2 mg/kg/h) for 150 min. In the control group (n = 10), an equivalent amount of saline was administered. Following the initiation of ischemia, an area of high-intensity NADH fluorescence rapidly developed in the middle cerebral artery territory in both groups and the DC potential in this area showed ischemic depolarization. An increase in NADH fluorescence closely correlated with the DC depolarization. The blood flow in the marginal zone of both groups showed a similar decrease. Five minutes after the onset of ischemia, the area of high-intensity NADH fluorescence was significantly smaller in the lidocaine group (67% of the control; P = 0.01). This was likely due to the suppression of ischemic depolarization by blockage of voltage-dependent sodium channels with lidocaine. Although lidocaine administration did not attenuate the number of pen-infarct depolarizations during ischemia, the high-intensity area and infarct volume were significantly smaller in the lidocaine group both at the end of ischemia (78% of the control; P = 0.046) and 24 h later (P = 0.02). A logistic regression analysis demonstrated a relationship between the duration of ischemic depolarization and histologic damage and revealed that lidocaine administration did not attenuate neuronal damage when the duration of depolarization was identical. These findings indicate that the mechanism by which lidocaine decreases infarct volume is primarily through a reduction of the brain area undergoing NADH fluorescence increases which closely correlates with depolarization.

Patients undergoing a panic attack (PA) or a hyperventilation attack (HVA) are sometimes admitted to emergency departments (EDs). Reduced serotonin level is known as one of the causes of PA and HVA. Serotonin is synthesized from tryptophan. For the synthesis of serotonin, vitamin B6 (Vit B6) and iron play important roles as cofactors. To clarify the pathophysiology of PA and HVA, we investigated the serum levels of vitamins B2, B6, and B12 and iron in patients with PA or HVA attending an ED. We measured each parameter in 21 PA or HVA patients and compared the values with those from 20 volunteers. We found that both Vit B6 and iron levels were significantly lower in the PA/HVA group than in the volunteer group. There was no significant difference in the serum levels of vitamins B2 or B12. These results suggest that low serum concentrations of Vit B6 and iron are involved in PA and HVA. Further studies are needed to clarify the mechanisms involved in such differences.

Purpose: The primary aim of this study was to investigate volume effect and safety of up to 50 mL/kg BW 6% hydroxyethyl starch (HES) 130/0.4 in adult and pediatric patients undergoing major elective surgery. The need to infuse human albumin may be reduced or avoided in Japan if these large doses 6% HES 130/0.4 can be infused. Methods: The study was an uncontrolled, open-labeled, multi-center trial. Fifteen adult and 5 pediatric patients undergoing major elective surgery received 6% HES 130/0.4 (Voluven&#174) with a maximum dose of 50 mL/kg from the start of surgery until 2 hours after the end of surgery according to a treatment algorithm. The primary efficacy endpoint was the volume effect of 6% HES 130/0.4 determined by the volume of saved albumin during the investigational period and the time course of hemodynamic stability in adult and pediatric patients. Safety parameters were fluid balance, hemodynamic and laboratory parameters ECG, local and systemic tolerance and adverse events. Results: Adult patients received a mean of 32.0 mL/kg of 6% HES 130/0.4. For 12 out of 15 adult patients an average amount of 1033.8 mL (18.6 mL/kg) albumin could be saved. The other 3 adult patients did not receive more than 1000 mL of HES 130/0.4. All pediatric patients received approximately 50 mL/kg of HES 130/0.4; for these patients an average amount of 39.9 mL/kg body weight albumin could be saved. The majority of adult patients, and all pediatric patients were hemodynamically stable at all 3 time points. The observed changes of the assessed laboratory parameters including hematological and coagulation parameters or in any other safety parameter determined did not reveal any safety concern related to the administration of 6% HES 130/0.4 up to doses of 50 mL/kg body weight. Conclusion: The study results indicate that 6% HES 130/0.4 has a reliable volume effect, could contribute to significant human albumin savings and was safe and well tolerated up to a maximum dose of 50 mL/kg body weight in adult and pediatric patients undergoing major elective surgery.

Even after successful resuscitation, hemorrhagic shock frequently causes pulmonary inflammation that induces acute lung injury (ALI). We previously demonstrated that when CO is inhaled at a low concentration both prior to and following hemorrhagic shock and resuscitation (HSR) it ameliorates HSR-induced ALI in rats due to its anti-inflammatory effects. In the present study, we administered CO to the same model of ALI only after resuscitation and examined whether it exerted a therapeutic effect without adverse events on HSR-induced ALI, since treatment of animals with CO prior to HSR did not prevent lung injury. HSR were induced by bleeding animals to achieve a mean arterial pressure of 30 mmHg for 1 h followed by resuscitation with the removed blood. HSR resulted in the upregulation of inflammatory gene expression and increased the rate of apoptotic cell death in the lungs. This was determined from an observed increase in the number of cells positive for transferase-mediated dUTP-fluorescein isothiocyanate (FITC), nick-end labeling staining and activated caspase-3. HSR also resulted in prominent histopathological damage, including congestion, edema, cellular infiltration and hemorrhage. By contrast, CO inhalation for 3 h following resuscitation significantly ameliorated these inflammatory events, demonstrated by reduced histological damage, inflammatory mediators and apoptotic cell death. The protective effects of CO against lung injury were notably associated with an increase in the protein expression level of peroxisome proliferator-activated receptor (PPAR)-γ, an anti-inflammatory transcriptional regulator in the lung. Moreover, CO inhalation did not affect the hemodynamic status or tissue oxygenation during HSR. These findings suggest that inhalation of CO at a low concentration exerts a potent therapeutic effect against HSR-induced ALI and attenuates the inflammatory cascade by increasing PPAR-γ protein expression.

Purpose There is no recommendation on how increased body temperature should be treated in non-neurological critically ill patients. To understand the epidemiology of fever and its association with mortality, we conducted a systematic review of the literature to search for data related to the association between fever and mortality. Materials and Methods We searched MEDLINE and PUBMED related articles and reference lists from January 1978 to July 2011 to select observational studies for assessment of the association of fever with mortality in non-neurological critically ill patients. Results We reviewed 1464 articles and found 9 relevant articles. We found that (1) there is no uniform definition of fever, (2) fever (37.5°C to >39.0°C) was not significantly associated with mortality (odds ratio, 1.22; P = .52), and (3) high fever (39.3°C to 39.5°C) was significantly associated with mortality (odds ratio, 2.95; P = .03). We also found that there has been no multicenter prospective observational study including important confounding factors, such as the use of antipyretic treatments, steroids, and extracorporeal circuits. Conclusions The limited evidence available suggests that the recommended definition of fever (38.3°C) might be too low to predict increased mortality. Because fever is common in the intensive care unit, there is an urgent need for more studies in this field.

Background Pharyngeal cooling decreases brain temperature by cooling carotid arteries. This study was designed to evaluate the principle of pharyngeal cooling in monkeys and humans. Methods Monkeys (n = 10) were resuscitated following 12 min of cardiac arrest. Pharyngeal cooling (n = 5), in which cold saline (5°C) was perfused into the cuff at the rate of 500 ml/min, was initiated simultaneously with the onset of resuscitation for 30 min. Patients (n = 3) who were in an intensive care unit were subjected to 30 min of pharyngeal cooling under propofol anesthesia. Results In the animal study, core brain temperature was significantly decreased compared with that in the control group by 1.9°C (SD = 0.8, P < 0.001) and 3.1°C (SD = 1.0, P < 0.001) at 10 min and 30 min after the onset of cooling, respectively. The cooling effect was more evident in an animal with low postresuscitation blood pressure. Total dose of epinephrine, number of direct current shocks, and recovery of blood pressure were not different between the two groups. The pharyngeal epithelium was microscopically intact on day 5. In the clinical study, insertion of the cuff and start of perfusion did not affect heart rate or blood pressure. Tympanic temperature was decreased by 0.6 ± 0.1°C/30 min without affecting bladder temperature. The pharynx was macroscopically intact for 3 days. Conclusions Pharyngeal cooling rapidly and selectively decreased brain temperature in primates and tympanic temperature in humans and did not have adverse effects on return of spontaneous circulation, even when initiated during cardiac arrest in primates.

Perioperative beta-blocker administration has recently been recommended for patients undergoing cardiac or other surgery due to the beneficial cardiovascular effects of these agents. In addition, some studies have reported that perioperatively administered beta-blockers also have analgesic effects. In this study, to investigate the antinociceptive effects and the analgesic profile of landiolol, we examined the effects of intrathecal landiolol administration on nociceptive pain behavior and c-fos mRNA expression (a neural marker of pain) in the spinal cord using a rat formalin model. We found that pain-related behavior was inhibited by intrathecal landiolol administration. Moreover, the increase in c-fos mRNA expression on the formalin-injected side was less pronounced in rats administered landiolol than in saline administered controls. Thus, intrathecal administration of landiolol exhibited antinociceptive effects. Further investigation of the antinociceptive mechanism of landiolol is required.

Little is known on the clinical effects of chloride on critically ill patients. We conducted this retrospective, observational study in 488 critically ill patients to investigate the incidence of chloride abnormalities, effects of hypochloremia in acid-base disorders, and association between chloride and clinical outcome. The study involved retrieval of arterial blood gas analyses, biochemical and demographical data from electrical records as well as quantitative acid-base analyses. For statistical analysis, the patients were stratified into three groups according to their chloride level (normal range: 98–106 mEq/L). The distribution of chloride levels was hyperchloremia 16.6%, normochloremia 74.6%, and hypochloremia 8.8%. The hypochloremic group was significantly alkalemic ( 𝑃 < 0 . 0 0 0 1 ) and has significantly higher apparent strong ion difference (SIDa) ( 𝑃 < 0 . 0 0 0 1 ) compared to the two other groups. The hypochloremic group had significantly longer stays in the ICU and hospital ( 𝑃 < 0 . 0 0 0 1 ) with higher mortality ( 𝑃 < 0 . 0 0 0 1 ). However, multiple regression analysis showed that chloride was not an independent factor of poorer outcome. In conclusion, the acid-base characteristics of the hypochloremic patients were alkalemia coexisting with higher SIDa. And although it was not an independent prognostic factor, hypochloremia was related to poorer outcome in critically ill settings.

The mechanism of oxygen toxicity for central nervous system and hyperbaric oxygen (HBO) seizure has not been clarified. Noradrenergic cells in the brain may contribute to HBO seizure. In this study, we defined the activation of noradrenergic cells during HBO exposure by c-fos immunohistochemistry. Electroencephalogram electrodes were pre-implanted in all animals under general anesthesia. In HBO seizure animals, HBO was induced with 5 atm of 100% oxygen until manifestation of general tonic convulsion. HBO non-seizure animals were exposed to 25 min of HBO. Control animals were put in the chamber for 120 min without pressurization. All animals were processed for c-fos immunohistochemical staining. All animals in the HBO seizure group showed electrical discharge on EEG. In the immunohistochemistry, c-fos was increased in the A1, A2 and A6 cells of the HBO seizure group, and in the A2 and A6 cells of the HBO non-seizure group, yet was extremely low in all three cell types in the control group. These results suggest the participation of noradrenaline in HBO seizure, which can be explained by the early excitement of A1 cells due to their higher sensitivity to high blood pressure, hyperoxia, or by the post-seizure activation of all noradrenergic cells.

Temporary brain ischemia occurring during surgery under general anesthesia may induce the death of neuronal cells and cause severe neurological deficits. On the other hand, it is not clear whether μ-opioid receptor agonists promote ischemic brain injury. It is known that duration of ischemic depolarization affects the degree of neuronal damage. However, the effects of fentanyl during brain ischemia on ischemic depolarization have not been investigated. Therefore, in the current study, the effects of fentanyl on ischemic neuronal damage and ischemic depolarization were quantitatively evaluated. Forty-two male gerbils were randomly assigned to a saline-administered group (control group, n = 21) and a fentanyl-administered group (fentanyl group, n = 21). Fentanyl at 50 μg/kg was first administered over a 10-min period and then 50 μg/kg/h was administered continuously for the fentanyl group. Forebrain ischemia was initiated by occlusion of bilateral common carotid arteries and sustained for 3, 5, or 7 min (n = 7 in each group). Direct-current potentials were measured in bilateral CA1 regions, in which histological evaluation was performed 5 days later. There were no significant differences in onset time, duration of ischemic depolarization, and percentage of neuronal damage between the two groups with any ischemic duration. In the relationships between ischemic time and neuronal damage and those between duration of ischemic depolarization and neuronal damage, there was no significant difference in the percentage of neuronal damage between the two groups. Fentanyl at a clinically relevant dose does not affect ischemic depolarization and ischemic neuronal damage.

The mechanism underlying neuropathic pain is still largely unclear. Recently, much attention has been focused on the role of brain-derived neurotrophic factor (BDNF) as a neuromodulator in the spinal cord. We previously reported that the expression of Bdnf exon I mRNA was remarkably up-regulated in the dorsal root ganglion (DRG) neurons with the rat L5 spinal nerve ligation (SNL) model. In the present study, we investigated whether neuropathic pain response would be reduced by the inhibition of the Bdnf exon I in the rat SNL model. We identified the promoter region of exon I and synthesized the decoy ODNs targeting the region. Reverse transcription-polymerase chain reaction analysis confirmed that the decoy ODN treatment reduced SNL-induced Bdnf exon I mRNA up-regulation in ipsilateral L4 and L5 DRGs. Furthermore, post-treatment with the decoy ODNs significantly attenuated SNL-induced tactile allodynia. This study suggested that decoy ODNs targeting the Bdnf exon I might provide a novel analgesic strategy for the treatment of neuropathic pain.

POPS研究会は，術後患者のQOLを高める術後疼痛管理サービス（Post Operative Pain Service：POPS）を標準化することを目的として活動している．その一環として，術後疼痛管理の全国アンケート調査を行ったので，一部を報告する．わが国における腹部手術の術後疼痛管理は，ディスポーザブルPCA注入器を用い，持続投与0.2%ロピバカイン4ml/h・PCA 3ml/回（充填時間30～60分）・フェンタニル0.3mg/日を2.5～3日間行う硬膜外PCAか，フェンタニル持続投与25μg/h・PCA 25μg/回（充填時間10分）を2～2.5日間行うIV-PCAが平均的であることがわかった．

Thrombotic microangiopathy (TMA) is a rare but potentially lethal complication encountered in solid organ and bone marrow transplant recipients that requires rapid recognition, diagnosis, and initiation of therapy. Several causes have been identified, including viral infections and various medications. We report a case of TMA after living-donor liver transplantation (LDLT). A 60-year-old man underwent LDLT for end-stage liver disease secondary to hepatitis C virus. After 6 months, he required re-transplantation because graft failure was caused by a small-for-size graft. The immunosuppressive regimen for the second transplantation consisted of tacrolimus and prednisolone; cyclosporine (CsA), mycophenolate mofetil, and prednisolone had been used for the first transplantation. Despite multiple transfusions of packed red blood cells and concentrated platelets, his hemoglobin and platelets decreased and lactate dehydrogenase increased following re-transplantation. Hematological evaluation revealed findings consistent with TMA. As soon as TMA was diagnosed, the calcineurin inhibitor (CNI) was changed from tacrolimus to CsA, and fresh frozen plasma (FFP) was given. The patient's platelets gradually increased after the CNI was changed, and no transfusions were needed. Therefore, tacrolimus was suspected as the cause of the patient's TMA. Early diagnosis, switching CNIs, and FFP supplementation allowed the TMA to resolve without the need for plasma exchange.

SummaryValidation of a scoring algorithm for non-overt disseminated intravascular coagulation (DIC) proposed by the International Society on Thrombosis and Haemostasis (ISTH) is still incomplete. It was the objective of this study to assess the impact of including AT to non-overt DIC scoring on the predictability for intensive care unit (ICU) death and the later development of overt-DIC defined by the Japanese Ministry of Health and Welfare (JMHW) or the ISTH. We performed a retrospective observational study conducted in 364 patients in critical care. Coagulation parameters obtained daily for DIC screening were utilised for scoring. There were 194 and 196 patients scored as positive non-overt DIC with and without AT, respectively; diagnostic agreement between the two was 78%. As compared with patients without non-overt DIC, these non-overt DIC patients had significantly higher mortality. In 37 ICU non-survivors, positive non-overt DIC scoring with AT preceded ICU death by a median of 6.8 days, which was significantly earlier as compared with a median of 5.4 days for non-overt DIC without AT (p=0.022). In patients who developed overt-DIC after admission, the time period from positive non-overt DIC to positive overt-DIC was significantly longer when AT was utilised (overt-DIC ISTH; 1.3 days vs. 0.1 days, p=0.004, overt-DIC JMHW; 2.5 days vs. 2.0 days, p=0.04, with AT vs. without AT, respectively). Non-overt DIC scoring predicted a high risk of death in critically ill patients. When information on AT levels was included, non-overt DIC scoring was found to predict development of overt-DIC significantly earlier than non-overt DIC scoring without AT.

Impaired deformability might contribute to the accumulation of activated leukocytes within pulmonary microcapillaries, leading to acute lung injury. The purpose of our study was to investigate changes in leukocyte deformability during periods of inflammation after esophagectomy. The study group comprised 20 patients who underwent esophagectomy. Changes in leukocyte deformability were investigated by examining filtration through a silicon microchannel, which simulated human pulmonary microcapillaries. Changes in the neutrophil cytoskeleton were investigated by measuring neutrophil F-actin assembly. The severity of patient clinical outcome was evaluated by the lung injury score. Leukocyte filtration through the microchannel was significantly weaker in esophagectomy patients than in healthy subjects (p

Hemorrhagic shock causes oxidative stress that leads to tissue injuries in various organs including the lung, liver, kidney and intestine. Excess amounts of free heme released from destabilized hemoproteins under oxidative conditions might constitute a major threat because it can catalyze the formation of reactive oxygen species. Cells counteract this by rapidly inducing the rate-limiting enzyme in heme breakdown, heme oxygenase-1 (HO-1), which is a low-molecular-weight stress protein. The enzymatic HO-1 reaction removes heme. As such, endogenous HO-1 induction by hemorrhagic shock protects tissues from further degeneration by oxidant stimuli. In addition, prior pharmacological induction of HO-1 ameliorates oxidative tissue injuries induced by hemorrhagic shock. In contrast, the deletion of HO-1 expression, or the chemical inhibition of increased HO activity ablated the beneficial effect of HO-1 induction, and exacerbates tissue damage. Thus, HO-1 constitutes an essential cytoprotective component in hemorrhagic shock-induced oxidative tissue injures. This article reviews recent advances in understanding of the essential role of HO-1 in experimental models of hemorrhagic shock-induced oxidative tissue injuries with emphasis on the role of its induction in tissue defense.

腎機能は新生児で成人の約7分の1, 肝機能は半分程度しかない. しかし生後約1年を過ぎるとほぼ成人に近い機能を備えることになる. では, 精神の発達は何歳で成人と同じになるのだろうか？精神発達の未熟な子どもたちが手術を受けなければならないと知ったとき, その不安や恐怖は安易に想像できるものではないだろう. 大きな不安を抱えたまま手術に臨むと, 術後に異常行動を起こしたり, 果ては術後の回復を遅らせたりもする可能性がある. また, 記銘障害や学習障害を受けたりする子どもも少なくない. こうした望ましくない反応を防ぐための介入には, 前投薬, 両親との同伴麻酔導入などの麻酔導入方法の検討, 術後鎮痛, などがあげられる. 前投薬が最も効果的なのは2～5歳くらいの学童期以前の小児ではあるが, 年長児に使用した報告もある. 親同伴で麻酔を導入することが子どもの不安を軽減する, との報告もあるが, ミダゾラム前投薬の方が効果的である. ただし, 同伴することは親の不安を軽減するし, これは子どもの不安軽減にもつながる. マスクか静注導入かは意見が分かれる. PCAやPCEAは小児でも安全かつ有効に使用でき, ぜひとも慣れておきたい鎮痛方法である. 子どもたちがストレスなく周術期を過ごし, ひいてはその後の健やかな成長・発達に寄与できるようわれわれも関与すべきであろう.

Suppression of peri-infarct depolarizations (PIDs) is one of the major mechanisms of hypothermic protection against transient focal cerebral ischemia. Previous studies have shown the lack of hypothermic protection against permanent focal ischemia. We hypothesized the lack of hypothermic protection was due to the poor efficacy in suppression of PIDs. To examine the hypothesis, we elucidated the effects of hypothermia on the manner of propagation of PIDs with temporal and spatial resolutions using NADH (reduced nicotinamide adenine dinucleotide) fluorescence images by illuminating the parietal-temporal cortex with ultraviolet light. Spontaneously hypertensive rats (n=14) were subjected to permanent focal ischemia by occlusion of the middle cerebral and left common carotid arteries. 2-h hypothermia (30 degrees C) was initiated before ischemia. Although hypothermia delayed the appearance of PIDs, it did not suppress their appearance. Furthermore, 54% of the PIDs enlarged the high-intensity area of NADH fluorescence in the hypothermia group, similar to the normothermia group (53%). The high-intensity area of NADH fluorescence widened by each PID was larger in the hypothermia group than in the normothermia group. These findings suggest that PIDs even in hypothermia are one of the major factors causing growth of infarction, emphasizing the importance of therapy that targets suppression of PIDs even during hypothermia.

We investigated changes in pain behavior after injection of acetic acid in the hindpaws of rats with L5 spinal nerve ligation (SNL)-induced neuropathy. We also examined immunoreactivity for acid-sensing ion channel 3 (ASIC3) in the dorsal root ganglion (DRG) of rats with L5 SNL. Two weeks after SNL, the withdrawal threshold to a mechanical stimulus was significantly lower in the SNL group than in the sham-operated group (n=9 per group, P0.01). After acetic acid injection, spontaneous pain responses in the SNL group were significantly increased compared to those in the sham-operated group (n=5, P0.05). L5 SNL significantly increased the proportion of total ASIC3-immunoreactive (ir) neurons in the ipsilateral L4 DRG compared to that in sham-operated rats (n=4, P0.01). Analysis of cell size showed that the proportion of large (1200 mm(2)) ASIC3-ir neurons in the ipsilateral L4 DRG significantly increased after L5 SNL (P0.05). In the ipsilateral L5 DRG, the proportion of ASIC3-ir neurons was not significantly affected by treatment. However, L5 SNL significantly increased (P0.01) the proportion of small (1200 mm(2)) ASIC3-ir neurons and significantly decreased (P0.01) the proportion of large ASIC3-ir neurons compared to proportions in sham-operated animals. These findings suggest that ASIC3 is associated with hyperalgesia in response to a chemical stimulus in the L5 SNL rat model.

Brain-derived neurotrophic factor (BDNF) expression changes in the dorsal root ganglion (DRG) and spinal cord in some pain models. Recently, rat BDNF transcripts containing novel 5' untranslated exons were identified and characterized, and a new numbering system for rat BDNF exons was introduced. We examined the expression profiles of these novel BDNF transcripts in bilateral L4/5 DRGs in an L5-selective spinal nerve ligation (SSNL) model and bilateral L5 DRGs in a complete Freund's adjuvant (CFA) model of rats. L5SSNL increased significantly (P

BACKGROUND: Despite the absence of objective neurological deficits, patients with chronic whiplash-associated disorder (WAD) complain of symptoms such as headache, dizziness, and nausea. These symptoms are also often experienced by patients with cerebrospinal fluid (CSF) leak. It was recently reported that radioisotope (RI) cisternography is useful in the diagnosis of intracranial hypotension due to CSF leak. We investigated the relation between chronic WAD and CSF leak by RI cisternography and evaluated whether epidural blood patch (EBP) administration is effective in the treatment of chronic WAD. METHODS: We studied 66 patients with chronic WAD with symptoms lasting longer than 3 mo. All patients underwent RI cisternography to determine the presence of CSF leak. In patients in whom CSF leak was identified, EBP was administered. Symptoms were assessed before, 1 wk after, and 6 mo after EBP. Work status was also assessed and follow-up RI cisternography was performed. RESULTS: Of the 66 patients, 37 showed CSF leak, and 36 of these patients received EBP 2.2 ± 0.7 times. The mean duration of symptoms was 33 mo. One week after EBP, the percentage of patients with symptoms was decreased significantly compared with that before EBP; headache: 100% vs 17%, respectively, memory loss: 94% vs 28%, dizziness: 83% vs 47%, visual impairment: 81% vs 25%, nausea: 78% vs 42% (P < 0.01). These effects were also observed at the 6 month follow-up examination (P < 0.01). Work status was also significantly improved at follow-up. CONCLUSIONS: We conclude that CSF leak should be considered in some cases of chronic WAD and that EBP is an effective therapy for chronic WAD.

Although propofol and thiopental are commonly used as neuroprotective agents, it has not been determined which is more neuroprotective. This study was designed to quantitatively evaluate the neuroprotective effects of thiopental, propofol, and halothane on brain ischemia by determining P50, ischemic time necessary for causing 50% neuronal damage. Gerbils were anesthetized with thiopental, propofol, or halothane and underwent 2-vessel occlusion (0, 3, 5 or 10 min). Direct current potentials were measured in bilateral CA1 regions, in which histologic evaluation was performed 5 days later. In some animals, extracellular glutamate concentrations (microdialysis) were measured during 7.5 minutes of ischemia. P50 in the thiopental, propofol, and halothane groups were estimated to be 8.4, 6.5 (P

麻酔導入時の筋弛緩薬は現在ベクロニウムが用いられることが多い. スキサメトニウムはその副作用から敬遠される傾向にあるものの, 1分程度で挿管可能となるため急速導入時に依然として広く使用されている. ロクロニウムは欧米ではすでに10年以上前から臨床使用され, 挿管までの時間をスキサメトニウムと同程度に短縮することが可能な非脱分極性筋弛緩薬であるが, 投与量の増加により作用持続時間は延長する. スガマデクスは, 抗コリンエステラーゼ薬とはまったく別の薬理作用で, ロクロニウムまたはベクロニウムによる神経筋遮断を迅速に拮抗する. 深い筋弛緩状態からの回復が可能となり, 筋弛緩薬の使用法を大きく変化させる可能性がある.

Optimizing the performance and increasing the comfort of high-speed trains require the knowledge of aerodynamic effects of a train shape. One of the most critical problems is a compression wave caused by a train entering a tunnel. This noise mainly depends on the cross-sectional area distribution of a train nose. On the other hand, the aerodynamic drag, the stability for side wind, and the low-frequency vibration are attributed to tail shapes. In this study, we studied the effects of train tail shapes on the flow field experimentally. Two models having the same cross-sectional area distribution but with different tail shapes were tested in a low-speed wind tunnel. To analysis the flow field around the model, we used pressure sensitive paint and oil flow techniques. As a result, we could identify the effects of tail shapes for pressure drag and cross wind stability.

昨今の生命科学の進歩は薬理学の研究をより病態に応じた新薬の開発へと向かわせている．しかし，肝不全，腎不全，多臓器不全など，急性臓器不全は高い死亡率を示すにもかかわらず，その治療において決め手となる薬物は未だ開発されていない．これら急性臓器不全の組織障害の病態生理は完全に明らかでないが，好中球の活性化や虚血・再潅流にともなう酸化ストレスによる細胞傷害が大きな役割を果たしている．酸化ストレスはヘムタンパク質からヘムを遊離させる．遊離ヘムは脂溶性の鉄であることから，活性酸素生成を促進して細胞傷害を悪化させる．この侵襲に対抗するために，ヘム分解の律速酵素：Heme Oxygenase-1（HO-1）が細胞内に誘導される．HO-1によるヘム分解反応産物である一酸化炭素，胆汁色素には，抗炎症・抗酸化作用がある．したがって，遊離ヘム介在性酸化ストレスよって誘導されたHO-1は酸化促進剤である遊離ヘムを除去するのみならず，これらの代謝産物の作用を介して細胞保護的に機能する．一方，HO-1の発現抑制やHO活性の阻害は酸化ストレスによる組織障害を悪化させる．この，HO-1の細胞保護作用に着目して，HO-1誘導を酸化ストレスによる組織障害の治療に応用する試みがなされている．本稿では，急性臓器不全モデルにおいて障害臓器に誘導されたHO-1が，遊離ヘム介在性酸化ストレスから組織を保護するのに必須の役割を果たしていることを述べる．また，抗炎症性サイトカイン：インターロイキン11，塩化スズ，グルタミンがそれぞれ，肝臓，腎臓，下部腸管特異的にHO-1を誘導し，これら組織特異的に誘導されたHO-1が標的臓器の保護・回復に重要な役割を果たしていることを示す．HO-1誘導剤の開発は急性臓器不全の新しい治療薬となる可能性を秘めている．

手術による出血死は麻酔関連偶発症による死亡症例の17%を占めている. 手術に伴う大量出血が発生し, 危機的状況へと拡大していく過程には, 術前の患者状態や病巣の癒着・浸潤のほかに, 手術の手技と判断, 麻酔管理, 血液製剤の準備と追加供給状況, 緊急避難的輸血による対応の有無など, さまざまなヒューマンファクターが関与している. 手術出血死を回避するためには, 医療機関の組織的対応能力と血液センターとの連携を向上させる必要がある.

Peripheral arterial disease often causes ischemic ulcers due to impaired blood flow and consequentially induces intractable pain. For these patients, we have recently begun to administer morphine orally. In this study, we retrospectively examined the effects of oral morphine for the relief of pain caused by peripheral arterial disease.Oral morphine was administered to 17 cases of peripheral arterial disease between January, 2004 and February, 2006. The initial dosage was 5 mg or 10 mg, started on an as-needed basis. After the daily dosage of morphine became constant, we divided the dosage into four or six times a day and administered it regularly. With the exception of one case, a small amount of oral morphine, from 20 mg to 70 mg a day, could alleviate patient's pain. Eight cases had side effects such as nausea, constipation or drowsiness.Oral morphine is effective for pain relief of peripheral arterial disease patients. However, now in Japan, oral morphine, which we can prescribe for those patients with insurance, has a shorter duration of action, so we need to administer slow-release morphine. Oral morphine must be administered carefully because many peripheral arterial disease patients have cardiac disease or renal dysfunction as complications.

To study the impact of pre-morbid glycemic control on the association between acute hypoglycemia in intensive care unit (ICU) patients and subsequent hospital mortality in critically ill patients.We performed a multicenter, multinational, retrospective observational study of patients with available HbA1c levels within the 3-month period preceding ICU admission. We separated patients into three cohorts according to pre-admission HbA1c levels (6.5, 6.5-7.9, ≥8.0%, respectively). Based on published data, we defined a glucose concentration of 40-69 mg/dL (2.2-3.8 mmol/L) as moderate hypoglycemia and40 mg/dL (2.2 mmol/L) as severe hypoglycemia. We applied logistic regression analysis to study the impact of pre-morbid glycemic control on the relationship between acute hypoglycemia and mortality.A total of 3084 critically ill patients were enrolled in the study. Among these patients, with increasing HbA1c levels from6.5, to 6.5-7.9, and to ≥8.0%, the incidence of both moderate (3.8, 11.1, and 16.4%, respectively; p0.001) and severe (0.9, 2.5, and 4.3%, respectively; p0.001) hypoglycemia progressively and significantly increased. The relationship between the occurrence of hypoglycemic episodes in the ICU and in-hospital mortality was independently and significantly affected by pre-morbid glucose control, as assessed by adjusted odds ratio (OR) and 95 % confidence interval (CI) for hospital mortality: (1) moderate hypoglycemia: in patients with6.5, 6.5-7.9, and ≥8.0 % of HbA1c level-OR 0.54, 95% CI 0.25-1.16; OR 0.82, 95 % CI 0.33-2.05; OR 3.42, 95 % CI 1.29-9.06, respectively; (2) severe hypoglycemia: OR 1.50, 95% CI 0.42-5.33; OR 1.59, 95% CI 0.36-7.10; OR 23.46, 95% CI 5.13-107.28, respectively (interaction with pre-morbid glucose control, p = 0.009). We found that the higher the glucose level before admission to the ICU, the higher the mortality risk when patients experienced hypoglycemia.In critically ill patients, chronic pre-morbid hyperglycemia increases the risk of hypoglycemia and modifies the association between acute hypoglycemia and mortality.