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We investigated dynamic cerebral autoregulation in 24 normocapnic adult patients during propofol and fentanyl anaesthesia. Hypotension was induced, to a mean arterial pressure (MAP) of 60–65 mmHg, using nitroglycerin or prostaglandin E1. Time-averaged mean cerebral blood flow velocity in the right middle cerebral artery was measured continuously using transcranial Doppler sonography. Dynamic autoregulatory response was activated by a sudden decrease in MAP following release of bilateral thigh cuffs (thigh cuff test) and evaluated as a dynamic rate of autoregulation (dRoR in %.s-1). The cuff test was repeated to obtain two values of dRoR during baseline and during induced hypotension; the data were then averaged. The mean value of dRoR during baseline and during induced hypotension was 14.2 (2.9) and 14.2 (1.6) %.s-1, respectively, in the nitroglycerin group, and 14.6 (2.6) and 14.4 (2.4) %.s-1, in the prostaglandin E1 group. We were unable to demonstrate significant between- or within-group differences in dRoR. Thus, we conclude that nitroglycerin and prostaglandin E1 do not attenuate dynamic cerebral autoregulation. [ABSTRACT FROM AUTHOR]

Yokukansan (YKS) is a traditional Japanese herbal (Kampo) medicine prescribed for anxiety. In this randomized controlled trial, we compared the subjective assessment of anxiety using questionnaires and its objective assessment using salivary alpha-amylase concentrations in YKS and control (CNT) groups of women undergoing breast surgery. The trial was registered at the University Hospital Medical Information Network Clinical Trials Registry (registration number: UMIN000028998), and the investigators were blinded to drug administration. One hundred patients who underwent breast cancer surgery were allocated to either the YKS or the CNT group. Finally, 35 and 42 patients in the YKS and CNT groups were analyzed, respectively. The YKS group received two 2.5 g doses of the medication before sleeping on the night before surgery and 2 h before inducing anesthesia, while the CNT group did not receive medication preoperatively. Patients answered two questionnaires, the Hospital Anxiety and Depression Scale and the State-Trait Anxiety Inventory, pre-and postoperatively as subjective anxiety assessments. As an objective anxiety indicator, salivary alpha-amylase levels were measured the day before, directly before, and the day after surgery (T3). In the YKS group, salivary alpha-amylase scores directly before operation were significantly lower than those on the day before surgery and at one day postoperatively (F [2,150] = 3.76, p = 0.03). Moreover, the Hospital Anxiety and Depression Scale-Anxiety and State-Trait Anxiety Inventory-Trait scores were significantly more improved postoperatively in the YKS group than in the CNT group (difference in Hospital Anxiety and Depression Scale-Anxiety: YKS, mean -2.77, 95% confidence interval [-1.48 --4.06], p <0.001, and CNT, -1.43 [-0.25--2.61], p = 0.011; and difference in State-Trait Anxiety Inventory: YKS group, -4.23 [-6.95--1.51], p = 0.0004; and CNT group, 0.12 [-2.36-2.60], p = 0.92). No side effects were associated with YKS. YKS may reduce perioperative anxiety in patients undergoing surface surgery., Competing Interests: The authors have declared that no competing interests exist.

We report 2 patients for whom anesthetic management using aortic occlusion balloon catheter (AOBC) was performed thrice. A 14-year-old boy and a 43-year-old man with sacral giant cell tumor underwent tumor resection. In both patients, transcatheter arterial embolization (TAE) was performed several times before the operation. Before the surgery, an AOBC was inserted via the right femoral artery. For tumor resection, the AOBC was inflated, and a slight decrease in hemorrhage was observed. The occlusion was maintained for 40-55 min, with a loss of 1,400-3,700 ml of blood. In case 1, moderate bleeding from the epidural venous plexus was observed. In case 2, packed red blood cell transfusion was needed, and the patient returned to surgery for hemostasis. Because the AOBC could not decrease the severity of venous hemorrhage, we expected increased hemorrhage with an increase in the extent of surgery. In addition, preoperative multiple TAE might lead to the development of collateral circulation around the sacrum and augment the amount of blood loss in that region. Although the AOBC could reduce intraoperative hemorrhage, uncontrollable bleeding may occur if the sacral giant cell tumor shows extensive dissemination.

A 37-year-old multigravida presented at 37 weeks of gestation with low-lying placenta and highly suspected placenta accreta. The placenta adhered widely to the anterior wall of the uterus. Therefore, a longitudinal incision of the uterine corpus at the thinnest part of the placenta was made during surgery. Concurrent with the incision, rapid and massive hemorrhage occurred. After the delivery of the baby and confirmation of the placental adhesion, the hysterectomy was started promptly. The bladder adhered strongly to the uterus, and was injured during the dissection. The total volume of hemorrhage was estimated to be 24,480 ml (including amniotic fluid and urine). No arterial clamp for hemostasis was used during the procedure. The patient was discharged on the 12th postoperative day with no sequela. The pathological diagnosis was placenta percreta. Placenta accreta is a rare disease with a high mortality rate. The hemorrhage becomes difficult to control in case of injury of placenta accreta. The hysterectomy following cesarean section also becomes complicated. Bladder injury is one of the complications of the cesarean hysterectomy which makes the hemorrhage greader. In conclusion, when placenta accreta is suspected a strategy to minimize blood loss during surgery should be discussed by a multidisciplinary team.

Unlabelled: We investigated the influence of drug-induced hypotension at a mean arterial pressure (MAP) of 60-70 mm Hg on cerebral pressure autoregulation in 45 adult patients during propofol-fentanyl anesthesia. Time-averaged mean blood flow velocity in the right middle cerebral artery (Vmca) was continuously measured at a PaCO(2) of 39-40 mm Hg by using transcranial Doppler ultrasonography. Hypotension was induced and maintained with a continuous infusion of nicardipine, nitroglycerin, or prostaglandin E(1). Cerebral autoregulation was tested by a slow continuous infusion of phenylephrine to induce an increase in MAP of 20-30 mm Hg. From the simultaneously recorded data of Vmca and MAP, cerebral vascular resistance (CVR) was calculated as MAP/Vmca. Furthermore, the index of autoregulation (IOR) was calculated as DeltaCVR/DeltaMAP, where DeltaCVR = change in CVR and DeltaMAP = change in MAP. The test was performed twice for each condition on each patient: baseline and hypotension. The IOR during baseline was similar among the groups. During nitroglycerin- and prostaglandin E(1)-induced hypotension, IOR was not different from baseline. In contrast, during nicardipine-induced hypotension, IOR significantly decreased compared with baseline (0.37 +/- 0.08 versus 0.83 +/- 0.07, P < 0.01). In conclusion, nicardipine, but not nitroglycerin or prostaglandin E(1), significantly attenuates cerebral pressure autoregulation during propofol-fentanyl anesthesia., Implications: Vasodilators may influence cerebral autoregulation by changing cerebral vascular tone. Nicardipine, but not nitroglycerin or prostaglandin E(1), attenuated cerebral pressure autoregulation in normal adult patients during propofol-fentanyl anesthesia.

Unlabelled: We investigated the effects of nicardipine on dynamic cerebral pressure autoregulation in 13 normal adult patients undergoing gynecologic or orthopedic surgery. Anesthesia was induced and maintained with propofol and fentanyl. Hypotension to a mean arterial pressure of 60-65 mm Hg was induced and maintained with a continuous infusion of nicardipine. Time-averaged mean blood flow velocity in the right middle cerebral artery was measured continuously by using transcranial Doppler ultrasonography. The cerebral autoregulatory responses were activated by releasing thigh cuffs. The actual blood flow velocity in the right middle cerebral artery response to acute change in mean arterial pressure was fitted to 1 of 10 computer-generated curves to determine the dynamic rate of cerebral autoregulation (dRoR), and the best fitting curve was used. The autoregulation test was repeated until two values of dRoR were obtained at baseline and during induced hypotension. Nicardipine significantly reduced dRoR values of 13.1% +/- 3.6%/s at baseline to 8.3% +/- 2.6%/s during hypotension (P: < 0.01). During deliberate hypotension induced by nicardipine, the cerebral dynamic autoregulatory response is impaired in normal adult patients., Implications: During deliberate hypotension induced by nicardipine, the cerebral dynamic autoregulatory response is impaired in normal adult patients.

Simultaneous measurements of time averaged mean blood flow velocity in the right middle cerebral artery (Vmca) by transcranial Doppler sonography (TCD) and regional cerebral oxygen saturation (rSo2) by near-infrared spectroscopy (NIRS) were performed in 30 subjects under propofol /fentanyl/ oxygen anesthesia. End-tidal CO2 pressure (PetCO2) was controlled by adjusting minute ventilation. A paired measurements of Vmca and rSo2 was repeated at PetCO2 of 50, 45, 40, 35, 30, and 25 mmHg in each subject. Relative Vmca (rVmca) was also calculated as a relative expression of Vmca at PetCO2 of 40 mmHg. Linear regression analysis was applied to determine the individual best fit relationship of these, parameters. There were significant linear correlations between PetCO2 and Vmca (R > 0.94, P < 0.01), between PetCO2 and rVmca (R > 0.94, P < 0.01), between PetCO2 and rSo2 (R > 0.92, P < 0.01), and between rSo2 and Vmca (R > 0.88, P < 0.05) in each subject. Furthermore, there was a significant linear correlation between rVmca based CO2 reactivity and rSo2 based CO2 reactivity (R = 0.60, P < 0.001). These results indicate that measurements of rSo2 may be an alternative method for evaluating cerebrovascular CO2 reactivity when poor ultrasound window.