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Purpose: To investigate the paths of thoracic epidural catheters in children, this retrospective study was performed., Methods: We investigated 73 children aged 4 to 12 (mean ± SD 7.8 ± 2.3) years, who underwent the Nuss procedure for pectus excavatum repair under combined general and epidural anesthesia over a 5-year period at Tokyo Metropolitan Police Hospital. Following induction of general anesthesia, we inserted a radiopaque epidural catheter via the T5/6 or T6/7 interspace and advanced for 5 cm cephalad in the thoracic epidural space. We evaluated the paths of the epidural catheters on plain chest radiographs after surgery., Results: The median level for the catheter tip location was T3 (range C6-T7), while the median number of vertebrae crossed by the catheter tips was 2.5. In most children, the catheters advanced straight for the first 2-3 cm (1-1.5 vertebrae) in the thoracic epidural space. However, they continued to advance straight in only 25 children, while they exhibited curved or coiled paths in the remaining 48. The catheter tips were located at higher levels in children with straight epidural catheter paths [median (range) T2 (C6-T4)] than in those with curved or coiled paths after the initial 2-3 cm [median (range) T4 (T2-T7)] (p < 0.0001)., Conclusions: Our findings indicate that the course of epidural catheters in children is unpredictable after the first 2-3 cm in the thoracic epidural space. Clinicians should be aware of such findings, although further studies are required for confirmation., (© 2022. The Author(s).)

Perioperative anaphylaxis is a severe adverse event during anesthesia that requires prompt diagnosis and treatment by physicians, including anesthesiologists. Muscle relaxants and antibiotics are the most common drugs that cause perioperative anaphylaxis in Japan, as in many countries. In addition, sugammadex appears to be a primary causative agent. Obtaining previous anesthesia records is necessary in a patient with a history of allergic reactions during anesthesia, whenever possible, to avoid recurrence of anaphylaxis. Although medical staff are likely to notice abnormal vital signs because of complete monitoring during anesthesia, surgical drapes make it difficult to notice the appearance of skin symptoms. Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia.Grade of recommendations and levels of evidence Anaphylaxis is a relatively rare condition with few controlled trials, and thus a so-called evidence-based scrutiny is difficult. Therefore, rather than showing evidence levels and indicating the level of recommendation, this practical guideline only describes the results of research available to date. The JSA will continue to investigate anaphylaxis during anesthesia, and the results may lead to an amendment of this practical guideline., (© 2021. Japanese Society of Anesthesiologists.)

Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.

Background: The sacroiliac joint (SIJ) is recognized as a potential source for low back pain especially in elderly people. Previous studies indicated that in patients with SIJ pain, posterior sacroiliac ligament injections are more effective than intra articular injections. The aim of this study was to assess usefulness of ultrasound sonography (US) in performing posterior sacroiliac ligament injection., Methods: We examined SIJ and ligaments, and injected local anesthetics using ultrasonography. US guided needle insertions were performed. We also examined the cadevar of a 74-year-old woman to examine SIJ anatomy., Results: US was performed in 61 male and 97 female outpatients (N = 158) with a mean age of 72.8 ± 10.9. US examination of the SIJ is difficult to perform because of its complex anatomy, and wide range of normal variations, and relative inaccessibility by surface scanning. The long posterior sacroiliac ligament (LPSL) is visualized as a hyper echoic laminated linear structure. We were able to confirm needle placement and area affected by local anesthetics., Conclusions: Our study suggests that US can be useful in performing posterior sacroiliac ligament injections. Sufficient anatomical knowledge and extensive US experience are essential in performing these injections.

Background: Lumbar spine disease in the elderly people is complicated by a variety of pathophysiology in the spine and the cause of the pain is unclear. Diagnosis of pain may be difficult in patients with pain in the thigh and groin area. Sacroiliac joint is supporting the trunk and movable joint. We examined the effect of the sacroiliac joint block for intractable low back pain., Methods: Retrospectively we examined the duration of disease in patients with hip and leg pain visiting the hospital for eight months, and we questioned the site of pain awareness. Newton test, Gaenslen test, Patrick test and Fadire test were carried out for sacroiliac joint pain in patients with at least one positive finding. When performing sacroiliac ligaments block local anesthetics was injected to check the position of the dorsal sacroiliac ligaments under ultrasonic echo whenever possible. The block is performed with the patients prone at a point one finger from the posterior superior iliac spine level at an angle of 30-45 degrees downward toward the outside. Injecting the drugs penetrating the ligament continued to give a feel slightly outward to avoid the iliac Cattelan 23 G needle. We confirmed pain assessment NRS at 11 (0-10), and the improvement of pain was assessed with the change of the NRS on the next return., Results: NRS showed a significant decrease at all points in time before block, their pain decreased gradually. The patients showed NRS improvement of more than 50% of the first block in 15 of 24 patients., Conclusions: Block at the posterior sacroiliac ligament region significantly reduced pain for chronic intractable low back pain. The block was shown to be effective as a treatment and for diagnosis.

A 74-year-old man was admitted to our hospital complaining of severe neck pain and general fatigue. He had been undergoing treatment for post-operative neck pain at the out-patient clinic of our hospital, but was now complaining of pain more intense than usual. Chest X-rays revealed diffuse ground glass shadows in bilateral lung fields, and computed tomography revealed diffuse intestinal shadows. A drug lymphocyte stimulation test (DLST) was also performed at that time. Steroid pulse therapy improved the clinical symptoms, hypoxemia and chest X-ray findings. DLST performed again with Yokukansan and Hachimijiogan 133 days after the initial diagnosis of pneumonitis showed Yokukansan was positive. This result showed Yukukansan may be a causative drug for allergic drug-induced pneumonitis. Any drugs including kanpo may be possible to induce allergic pneumonitis.

Yokukansan, one of the traditional Japanese herbal medicines, ameliorated neuropathic pain symptoms in patients. In this study, we investigated the effects of yokukansan on neuropathic pain in chronic constriction injury (CCI) model. Oral administration of yokukansan significantly inhibited mechanical and cold allodynia in the von Frey hair or acetone test, respectively. In comparison, amitriptyline, a tricyclic antidepressant, demonstrated moderate, but not significant, antiallodynic effects in the mechanical and cold tests. Yokukansan significantly inhibited the cerebrospinal fluid dialysate level of glutamate that had increased by the stimulation of brush or acetone. Glutamate transporter inhibitors, DL-threo-beta-hydroxy aspartate and dihydrokainate, decreased the yokukansan-induced antiallodynic actions in CCI rats. Our results suggest that yokukansan was confirmed to have antiallodynic effects in CCI rats, which are related to a blockade of glutamatergic neurotransmission via activation of glutamate transporters in the spinal cord.

Background: Remifentanil recently comes to be used for intraoperative analgesia instead of epidural anesthesia in gynecological surgery. It seems to offer the same stability in vital signs, but stress response during remifentanil anesthesia has not been evaluated. Therefore, we compared remifentanil anesthesia with epidural anesthesia regarding stress hormones., Methods: Fifty-one patients scheduled for surgery were randomized into two groups (epidural group: E and remifentanil group: R). Anesthesia was maintained with propofol and epidural ropivacaine in E, and with propofol and remifentanil in R. Plasma concentrations of adrenaline, noradrenaline, dopamine (DOA), cortisol, adorenocorticotropic hormone (ACTH), and blood glucose were measured at five points during the perioperative period., Results: Adrenaline, noradrenaline and blood glucose were not significantly different between the groups at any point. DOA was significantly higher in R than E at skin closure. Cortisol was significantly higher in R than E at three points during operation. ACTH was significantly higher in E than R at skin closure., Conclusions: The inhibition of stress hormone secretion during operation was less in R than E. Regarding stress response, total intravenous anesthesia with remifentanil seems to be a proper method, but to have less potency than general anesthesia using epidural block.

A healthy 29-year-old woman received epidural block for severe lumbago in an outpatient clinic. Fifteen minutes after injection of mepivacaine 0.5% with dexamethasone into the epidural space, the patient complained of itching of eyelids followed by generalized pruritus. Hypotension, erythema and generalized urticaria were observed. Initial treatment was with 100% oxygen through face mask, and additional intravenous fluids, followed by administration of adrenaline, chlorpheniramine and dopamine. Cardiac ultrasound examination showed mildly impaired movement of inferior to septal wall. Her plasma histamine level was transiently elevated during the anaphylactic event; however the serum tryptase level was not. Biological assays for confirming the causative agent and cutaneous test were all negative, but clinical symptoms positivity showed nonimmunological anaphylactic reaction to mepivacaine or dexamethasone. This case report confirms the need for systematic allergological investigation in a case of immediate hypersensitivity reaction occurring during nerve block in patients who had even received similar nerve blocks repeatedly. Pain clinician should be aware of the possibility of anaphylactic reactions involving any drug or substance used for an outpatient.

Background: Epidural catheter insertion is a common procedure in gynecological surgeries. At a previous study, we investigated the catheter's direction and position, inserted 7cm cephalad from T12-L1, with postoperative plain X-P using picture archiving communication system (PACS). 74% of the catheters advanced in cephalad direction and 71.4% of the catheter tips stayed within one vertebra from the puncture level. We estimated that the catheters were too long to advance straight. Then, we planned another prospective study to compare the catheter advanced 7 cm or 5 cm regarding its direction and tip position., Methods: Fifty-one female patients receiving gynecological surgery were enrolled. Epidural catheters were inserted from T12-L1 intervertebral space in cephalad direction for the length of 5 cm confirmed with postoperative plain X-P using PACS. The catheter's direction, the length, and the position were verified and compared with the result of the previous study., Results: The catheters going cephalad appeared more frequently among 5 cm group than 7 cm group. Those going caudalad appeared more frequently among 7 cm group than 5 cm group. However, the catheter tip final position and the length from the puncture levels were not significantly different between the groups., Conclusions: The direction and the position of epidural catheter inserted 5 cm or 7 cm cephalad did not differ.

Background: The purpose of this study is to examine the accuracy of the Fukuda Denshi DS-7000 noninvasive blood pressure measurement device equipped with two cuff deflation mode: a normal mode and quick mode., Methods: Twenty-one patients undergoing elective surgery were divided into two groups by using cardio-ankle vascular index (CAVI): no atherosclerotic group and atherosclerotic group. During anesthesia, two modes of blood pressure measurements were examined with the normal mode followed by the quick mode., Results: All the patients completed the study, resulting in a total of 1034 paired blood pressure measurements. In both no atherosclerotic group and atherosclerotic group, there were statistically significant correlations among systolic, diastolic and mean blood pressure in two modes. This results certified the accuracy of the quick mode measurement., Conclusions: The newly developed rapid oscillometric blood pressure measurement can be useful for perioperative management especially in atherosclerotic patients.

Background: Neuropathic pain that is the chronic, severe, and intractable pain, interferes with activities of daily living (ADL) and consequently reduces quality of life (QOL). We reported the efficacy of Yokukansan in patients with neuropathic pain, including acute herpetic pain, postherpetic neuralgia, central poststroke pain, post-traumatic spinal cord injury pain, thalamic syndrome, complex regional pain syndrome and symptomatic trigeminal neuralgia. Yokukansan was more effective compared with traditional medicines, such as tricyclic antidepressants, carbamazepine, gabapentin, and opioids etc., which are recommended to treat neuropathic pain. Recently, effects of Yokukansan is reported on the behavioral and psychological symptoms of dementia (BPSD) in elderly patients with dementia. Repeated administration of Yokukansan decreases expression of 5-hydroxytryptamine (5-HT) 2A receptors in the prefrontal cortex in mice, and Yokukansan also protects destruction of myelin sheaths in rats with thiamine deficient-induced encephalopathy. Mechanism of effectiveness of Yokukansan on neuropathic pain has not been established; however, efficacy of Yokukansan on neuropathic pain has been shown clinically., Conclusions: As far as we know, this is the first report that Yokukansan was effective on neuropathic pain. Yokukansan without serious adverse reactions may be a possible medicine for treatment of neuropathic pain in future.

Background: Epidural catheter insertion is a common procedure for gynecological surgeries. Epidural puncture is usually performed according to the anatomical landmarks without radiographic means. The aim of his study was to confirm the actual level of puncture, and the distance as well as the direction of epidural catheters threaded., Methods: Seventy-seven female patients receiving epidural anesthesia were enrolled. Epidural catheter was inserted from T12-L1 intervertebral space in cephalad direction for the length of 7 cm. The catheter was confirmed with postoperative plain X-P using picture archiving communication system. The intended direction and length were compared with the actual data. In addition, we retrospectively analyzed the factors including the performers (resident vs. specialist), the approaches of puncture (median vs. paramedian), and patient physical factors (age, height, body weight, and BMI)., Results: Of the catheters 54.6% was inserted from T12-L1, and 74% of them were advanced in cephalad direction. Of the tip of the catheter 71.4% stayed within one vertebra from the puncture level. The puncture accuracy, the frequency of catheter threaded over one vertebra, and the frequency of catheters threaded in cephalad direction did not differ significantly among performers, approaches and patients physical factors., Conclusions: Only 11.7% of the catheters were actually inserted from T12-L1 and advanced in cephalad direction over one vertebra as we had intended.

Background: Patient controlled epidural analgesia (PCEA) is a useful method in alleviation of postoperative pain; however, PCEA sometimes provided inadequate pain relief in the elderly. Therefore, we investigated optimal doses of fentanyl by PCEA in management of postoperative pain after gynecological surgery in the elderly., Methods: We investigated the pain at rest using 100 mm visual analogue scale (VAS) on the 1st day and 2nd day after the operations. Patients were divided into two groups ; one was well-controlled group (WC group, VAS < 20 mm) and the other was poorly-controlled group (PC group, VAS > or =20 mm). In two groups, we retrospectively compared doses of fentanyl in PCEA, number of demand-PCEA, postoperative nausea as well as vomiting, and delirium during 48 hrs after the operations., Results: The mean age in WC group was significantly higher than that in PC group. The total dosage of epidural fentanyl did not differ significantly between the groups. In WC group fentanyl of 0.172 microg x kg(-1) hr(-1) was given, and fentanyl 0.197 microg x kg(-1) x hr(-1) in PC group., Conclusions: We found that fentanyl 0.172 microg x kg(-1) x 1 hr(-1) by PCEA was the most appropriate dose for alleviation of postoperative pain after gynecological surgery in the elderly.

Yokuininto was effective in treating burning pain in both lower legs of a 58-year-old woman. She felt her lower legs feverish: however, no neurological deficit or abnormal finding in angiography was found. The burning pain was increased by cold and decreased by warm, but was alleviated by epidural block with local anesthetics. After 2-week medication of Yokuininto, burning pain was reduced to 20 to 30% and fever in legs disappeared. Yokuininto has been used for chronic pain in muscle and joint accompanied by swelling or local fever. This patient had no joint pain or swelling, but her burning pain was considered to have resulted from some abnormality in blood circulation due to disorder in discharge of water in the body.

Background: The incidence of herpes zoster increases with age. Immediate pain relief is required for prevention of postherpetic neuralgia (PHN) and also its related symptoms that worsen the general condition because acute herpetic pain often interferes with sleep, mood, and general activities in elderly patients. Nerve block is useful to relief acute pain and recommended for prevention of PHN. Tricyclic antidepressant drugs have antinoticeptive effect in acute pain in experimental models, in addition to its antidepressant effect., Methods: Forty elderly patients with herpes zoster within 3 months after the onset underwent nerve blocks and received tricyclic antidepressant drugs. We assessed the effect of treatments and adverse effects., Results: No significant adverse effects were found in elderly patients who had received nerve blocks and/or tricyclic antidepressant drugs. Alleviation of acute pain was obtained in more than 80% of patients, and in all patients depressive state and/or disturbance of the general condition were significantly improved., Conclusions: With careful technique and assessment of patients, both nerve block and tricyclic antidepressant drugs were beneficial and safe treatments in elderly patients with herpes zoster.

Recent studies demonstrate that vasopressin is useful when treating hemorrhagic and septic shock. The effect of vasopressin on systemic anaphylaxis has not been investigated except in clinical case reports. Vasopressin increases blood pressure because of vasoconstriction through the V1 receptor. Thus, we evaluated the effect of vasopressin on circulatory depression and bronchoconstriction provoked by systemic anaphylaxis and survival rates in rabbits. In the first set of experiments, 15 nonsensitized rabbits received normal saline (control) and vasopressin at 0.8 or 0.08 U/kg. In the second set, 40 sensitized rabbits received horse serum to induce anaphylaxis, and then received the same drugs as in the first set. In the first set, mean arterial pressure (MAP) in vasopressin groups increased by 18% to 24% compared with the control. Vasopressin at 0.8 U/kg decreased MAP insignificantly before the increases of MAP occurred. In the second set, vasopressin at 0.08 U/kg improved the survival rate. At 45 min after antigen challenge, 69% of the rabbits that received vasopressin at 0.08 U/kg were alive, whereas 29% of the control rabbits and 23% of the rabbits that received vasopressin at 0.8 U/kg were alive. Vasopressin increased MAP by 36% to 109% compared with the control within 5 min, however, at 2 min, vasopressin at 0.8 U/kg had no effect on MAP. Pulmonary dynamics were similar. In conclusion, vasopressin at 0.08 U/kg improved survival rates and severe hypotension provoked by systemic anaphylaxis, suggesting that this agent may be useful in the treatment of systemic anaphylaxis.

Study Objective: To compare the analgesic efficacy of additional 0.1% bupivacaine to patient-controlled epidural analgesia (PCEA) using buprenorphine and droperidol after gynecological surgery., Design: Randomized, double-blinded study., Setting: Operating theater and general ward at Jichi Medical School Hospital., Patients: Thirty patients with American Society of Anesthesiologists physical status I and II scheduled for gynecological surgery., Interventions: Patients received combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia. Patients were assigned to receive PCEA with or without 0.1% bupivacaine. Group 1 (n = 15) received buprenorphine 20 microg and droperidol 0.1 mg diluted with saline, and group 2 (n = 15) received bupivacaine 2 mg, buprenorphine 20 microg, and droperidol 0.1 mg diluted with saline (0.1% bupivacaine solution) in a bolus dose of the PCEA, respectively. No background epidural infusion was used., Measurements: Visual analog pain scale (VAPS) scores at rest and on coughing, and cumulative frequency of self-administrated analgesic solution in PCEA were recorded at 24 and 48 hours postoperatively., Main Results: There were no significant differences noted between the groups in VAPS scores at rest or in cumulative volumes of PCEA solution in 24 or 48 hours postoperatively. Median VAPS scores on coughing in group 2 were significantly lower than those values in group 1 at 24 hours (36 vs 65 mm, P < .001) and 48 hours (32 vs 54 mm, P = .036) postoperatively., Conclusions: Addition of 0.1% bupivacaine to PCEA using buprenorphine and droperidol provides better analgesia on coughing after gynecological surgery.

Purpose: The present study was done to investigate the role of endothelin-1 (ET-1) in hypotension and bronchospasm provoked by anaphylaxis in rabbits in vivo., Methods: Forty-five rabbits sensitized to horse serum were randomly allocated to five groups: Group 1 (n = 10) received 0.5 nmol x kg(-1) of ET-1; Group 2 (n = 10) received 0.5 nmol x kg(-1) of ET-1 and 200 nmol x kg(-1) of a selective ETA receptor antagonist, BQ 610, without anaphylaxis; Group 3 (n = 5) received 200nmol x kg(-1) of BQ 610 alone without anaphylaxis, Group 4 (n = 10) received normal saline alone before being antigen challenged to induce anaphylaxis; Group 5 (n = 10) received 200 nmol x kg(-1) of BQ 610 before antigen challenge., Results: Mean arterial pressure (MAP) values were significantly different between Groups 1 and 2. Heart rate (HR), central venous pressure (CVP), dynamic pulmonary compliance (C(dyn)), and pulmonary airway resistance (R(L)) did not differ significantly between Groups 1 and 2. MAP values were significantly decreased compared with baseline in both Groups 4 and 5; however, the values were not significantly different between two groups. CVP values were significantly different between Groups 4 and 5 only at the 15-min time point following antigen challenge. HR, R(L), and C(dyn) values were not significantly different between Groups 4 and 5, nor were the survival rates., Conclusion: BQ 610 does not improve hypotension or survival rates in systemic aggregated anaphylactic rabbits in vivo, implying that circulating ET-1 may not play an important role in anaphylaxis, although direct proof of production of circulating ET-1 or activation of ETA receptors is lacking in this study.

We did an obstetric management of a parturient, aged 32 years, with a history of local anesthetic hypersensitivity. The results of histamine release test, and cellular antigen stimulation test with lidocaine, mepivacaine, bupivacaine and preservative-free lidocaine during her pregnancy showed that all local anesthetics studied were positive. We used diphenhydramine as an alternative local anesthetic for episiotomy to the parturient during the delivery. Infiltration with diphenhydramine provided adequate analgesia without noticeable adverse reaction. One month after the delivery, we performed provocative challenge test with local anesthetics, and confirmed she had positive tests to lidocaine, mepivacaine and preservative-free lidocaine, and negative test to bupivacaine. Diphenhydramine is an adequate alternative of local anesthetics in patients with history of hypersensitivity to local anesthetics.

To assess the analgesic efficacy and side effects of a supplemental night-time infusion in patient-controlled epidural analgesia (PCEA) after gastrectomy, we carried out a randomized, double-blind study. The number of requests were lower (P<0.005) in the PCEA plus night-time infusion group than in the PCEA alone group during the postoperative nights. Patients who had a PCEA plus night-time continuous infusion, slept with fewer interruptions than those who had only the PCEA. VAS pain scores on coughing were significantly lower (P<0.05) in the PCEA plus infusion group than in the PCEA alone group during the night following postoperative day 1. In conclusion, a night-time infusion in PCEA following gastrectomy decreases the incidence of postoperative pain, provides a better sleep pattern, and reduces the degree of the pain associated with coughing during the night.

Analgesic efficacy of repeated application of a lidocaine cream formula was investigated in herpes zoster patients with subacute pain with no further improvement after continued treatment since their acute stage (S-HZ group, n = 23), and in patients to whom past treatments had not provided adequate pain relief (PHN group, n = 28). In both groups, visual analog scale (VAS) values decreased significantly from their corresponding values before the present treatment with few cases of side effects and complete disappearances of the pain in 21.6% of all the patients. The results indicate that the repeated application of the lidocaine cream is a safe and effective treatment method. Significantly higher effectiveness was achieved in the S-HZ group in terms of the difference in the VAS values between before and after the treatment, effectiveness in improving the activities of daily life, and overall efficacy evaluation.

The present study was conducted to determine whether an inhibitor of phosphodiesterases 4 and 1, KF19514, is useful in the treatment of systemic anaphylaxis in fentanyl-anesthetized rabbits. Eighty-two rabbits were randomly allocated to 7 groups. Groups I-1 (0.01 mg x kg(-1)), I-2 (0.1 mg x kg(-1)), and I-3 (1 mg x kg(-1)) received KF19514 10 minutes before antigen challenge, with Group II serving as control. Group IV and Group V received KF19514 and aminophylline 1 minutes after antigen challenge, respectively, with Group III serving as control. The survival rate was higher in Groups I than in Group II, rates were similar in Groups I-1, I-2, and I-3. The survival rate was also higher in Group IV than in Group III. Pulmonary resistance (R(L)) was significantly lower in Groups I-2 and I-3 than in Group II. Dynamic pulmonary compliance (C(dyn)) was significantly higher in Group I-3 than in Group II. Heart rate and central venous pressure were similar in Groups I and II. In Groups III, IV, and V, heart rate and mean arterial pressure were comparable, but central venous pressure in Group IV was significantly lower than in Group V. In conclusion, the administration of KF19514, an inhibitor of PDEs 4 and 1, to rabbits either before or after antigen challenge improved bronchoconstriction provoked by systemic anaphylaxis with minimal concomitant cardiovascular side effects compared with aminophylline, suggesting that this agent may be useful in the treatment of systemic anaphylaxis.

We report the performance and our impression of five patient-controlled analgesia (PCA) drug delivery devices commercially available; Atom PCA Pump 500, AP-II, Deltec CADD-PCA 5800, Sabratek 6060 and Verifuse. Each of these devices has unique features for PCA. However, these devices still leave some room for improvement. Especially, we hope that future devices will be lighter to carry and use dry batteries more economically. In order to use these devices effectively for the management of pain, it is important to understand their characteristics.

We evaluated effects of continuous epidural infusion on postoperative pain, and frequency of its side effects. Patients who had undergone elective gynecological operations were randomly allocated into three groups by difference in duration of indwelling of epidural catheters: patients receiving epidural block only during operations (group M); patients receiving continuous epidural infusion for 2 postoperative days (group B 2); patients receiving continuous epidural infusion for 4 postoperative days (group B 4). In group M, morphine 3 mg and 1 or 2% lidocaine 5-7 ml were given before the start of operation, and epidural catheter was removed after the end of operations. In group B 2 and B 4, morphine 2 mg and 1 or 2% lidocaine 5-7 ml were given before the start of operation, and morphine 8 mg in 50 ml of 0.25% bupivacaine was continuously infused at a rate of 0.5-1 ml.hr-1. We evaluated visual analogue scale (VAS) at rest and moving, and verbal descriptor pain score. Frequencies of supplementary analgesics, vomiting and nausea, residual urine volume after removal of bladder catheter, and timing to initiation of bowel movement after operation were also recorded. VAS at rest was significantly higher in group M than in groups B 2 and B 4 for 2 postoperative days, but no significant difference was seen between the three groups for three postoperative days. VAS at moving did not differ between the 3 groups. Verbal descriptor pain score was significantly higher in group M than in groups B 2 and B 4 for 3 postoperative days, but it was not different between groups B 2 and B 4. In group B 2, patients complained increased abdominal pain after removing catheters. Frequencies of supplementary analgesics were 3.7, 0.6 and 0.4 times in group M, B 2, B 4, respectively. Times to initiation of bowel movement after operation were 39.8, 46.5 and 61.7 hrs in group M, B 2, and B 4, respectively, and most patients in group B 4 felt uncomfortable. These results suggest that continuous epidural analgesia for 2 postoperative days is appropriate, but the duration should be determined according to patient's conditions and complications.

Purpose: The aims of the present studies were to determine whether the systemic hypotensive response to protamine was modified in rats pre-treated for two weeks with the nitric oxide synthase inhibitor, NG-nitro-L-arginine-methyl ester (L-NAME), and to evaluate the inhibitory effect of heparin on the systemic hypotensive response to protamine in vivo., Methods: Male rats were randomly assigned into four groups. Normal saline 12 microliters.day-1, D-NAME (an inactive enantiomer of L-NAME), 10 mg.kg-1, L-NAME, 1 or 10 mg.kg-1.day-1 i.p. was administered for two weeks and the haemodynamic changes were measured after protamine administration. In another experiment, male rats were assigned to two groups. In one, the heparin group, protamine was administered after heparin had been administered and in the other, protamine group, protamine alone was administered., Results: L-NAME inhibited the decrease in systemic arterial pressure after protamine administration (P < 0.05), but D-NAME had no effect. Also, heparin reduced the decrease in systemic arterial pressure after protamine (P < 0.05)., Conclusion: Nitric oxide is mainly responsible for mediation of the systemic hypotensive response to protamine which is also reduced by heparin.

Unlabelled: To assess the analgesic efficacy and side effects of concurrent infusion in patient-controlled epidural analgesia (PCEA) after upper abdominal surgery, 40 patients undergoing elective gastrectomy under general anesthesia were allocated to two groups in this randomized, double-blind study: one received a 2.5-mL incremental bolus in a solution of 0.2% bupivacaine and 10 microg/mL fentanyl, and the other received the same bolus dose plus a 2.5-mL/h infusion of the same solution. The number of demands was smaller (P < 0.001) in the PCEA plus infusion group than in the PCEA alone group during the 48-h postoperative period. The average hourly fentanyl and bupivacaine doses were larger (P < 0.0001) in the PCEA plus infusion group than in the PCEA alone group. Visual analog scale pain scores on coughing in the PCEA plus infusion group were lower than in the PCEA alone group (P < 0.05). There was a greater incidence of pruritus in the PCEA plus infusion group (P < 0.05), but no serious side effects were observed in either group. In conclusion, a background infusion in PCEA with a mixture of fentanyl and bupivacaine decreases the incidence of postoperative pain and reduces the degree of pain associated with coughing without serious side effects after gastrectomy., Implications: A background infusion in patient-controlled epidural analgesia with a mixture of fentanyl and bupivacaine decreased the incidence of postoperative pain and reduced the degree of the pain associated with coughing without serious side effects in this randomized, double-blind study after gastrectomy.

We report the management of anesthesia for emergent tracheostomy in a patient with severe tracheal stenosis. A 63-year-old male was scheduled for an emergency tracheostomy for severe tracheal stenosis due to the invasion of a thyroid cancer. A preoperative neck CT revealed the tracheal stenosis, extending from 1-2 cm below the vocal cord to the upper end of the sternum. The narrowest caliber was about 7 mm in transverse diameter. Moreover, the cancer was suspected to have a bleeding tendency. General anesthesia with endotracheal intubation was considered necessary to provide an open airway during tracheostomy. Anesthesia was induced with thiopental, and a 6.0 mm endotracheal tube with cuff was successfully introduced with a balloon introducer (AIRGUID E) using suxamethonium. We were able to perform tracheostomy uneventfully.

Exposure of sensitized perfused rabbit lungs to human O-N type erythrocytes leads to pulmonary vasoconstriction and bronchoconstriction. To investigate whether platelet-activating factor (PAF) is a mediator of pulmonary vasoconstrictive and bronchoconstrictive responses after antigen challenge, we administered antigenic erythrocytes after the administration of PAF antagonist (.1 mg/kg; CV6209). Pulmonary arterial and airway pressures significantly increased after antigen challenge in the sensitized rabbit lungs, but not in the nonsensitized rabbit lungs. CV6209 significantly inhibited these pulmonary vasoconstrictive and bronchoconstrictive responses after antigen challenge. We concluded that PAF, at least in part, plays an important role in pulmonary vasoconstriction and bronchoconstriction after antigen challenge in rabbits.

We investigated whether an inhibitor of poly(adenosine 5'-diphosphoribose) synthetase (PARS) is beneficial in anaphylaxis. Twenty-eight rabbits were randomly allocated to three groups: Group I (control) received .9% NaCl solution 10 min before antigen challenge followed by the infusion of the same solution. Group II (3-aminobenzamide 20 mg.kg-1) received 20 mg.kg-1 of 3-aminobenzamide (a PARS inhibitor) 10 min before antigen challenge followed by the continuous infusion of 20 mg.kg-1 of 3-aminobenzamide. Group III received 40 mg.kg-1 10 min before antigen challenge followed by the continuous infusion of 20 mg.kg-1 of 3-aminobenzamide. Survival were similar between three groups. Heart rate, mean arterial pressure (MAP), central various pressure, and pulmonary resistance did not differ between three groups. Dynamic pulmonary compliance did not differ in the early phase after the antigen challenge; however, it was significantly lower in Group III than in Groups I and II 15 min after the initiation of anaphylaxis. 3-aminobenzamide per se did not affect heart rate, MAP, central venous pressure, pulmonary resistance, or dynamic pulmonary compliance in animals without systemic anaphylaxis. In conclusion, this PARS inhibitor did not improve cardiovascular depression or bronchospasm in the early phase of systemic aggregated anaphylaxis in rabbits in vivo, implying that the pathophysiological changes associated with systemic anaphylaxis may not be related to activation of an energy-consuming DNA repair cycle triggered by PARS.