Impact of immunoreactive substances contained in apheresis platelet concentrate on postoperative respiratory function in surgical patients receiving platelet transfusion: a prospective cohort study.

OBJECTIVES: To construct an alternative policy for the donor selection of platelet concentrate (PC), a clinical study exploring the features of lung injury following PC administration is needed. BACKGROUND: Although a male-donor-only policy for plasma products appears to have efficiently reduced transfusion-related acute lung injury (TRALI), this policy may not be applied to PC because of supply shortages. METHODS AND MATERIALS: We prospectively examined pulmonary function after the transfusion of PC in informed surgical patients treated at a tertiary university hospital in Japan. The contributions of immunoreactive substances contained in the PC to respiratory function after PC transfusion was then statistically examined. RESULTS: Eighty-six patients (56 men, 30 women) were enrolled in the analysis. Fifty-four cases experienced respiratory failure (PaO2 /FiO2 <300 mmHg) after transfusion. Five cases were diagnosed as possible TRALI based on permeability pulmonary oedema, while 23 cases were diagnosed as transfusion-associated circulatory overload (TACO) based on chest radiograph findings. A multivariate logistic regression analysis identified the presence of anti-granulocyte antibody as a significant predictor of possible TRALI [P = 0.023; odds ratio (OR), 13.0; 95% confidence interval (CI), 1.4-118.3]. Meanwhile, anti-leukocyte antibody class II was identified as a significant independent predictor of TACO (P = 0.010; OR, 18.4; 95% CI, 2.0-170.1). CONCLUSIONS: Our data suggest that antibodies contained in PC may contribute to the deterioration of respiratory function after PC transfusion, although the diagnoses of TACO and TRALI may have overlapped among the patients with pulmonary distress in this cohort.

Effects of sublingual nitrate in patients receiving sustained therapy of isosorbide dinitrate for coronary artery disease.

To examine the effects of sublingual isosorbide dinitrate (ISDN) in patients receiving sustained ISDN therapy, 24 patients with coronary artery disease were divided into 2 groups. Group C comprised 12 patients without sustained ISDN therapy and group N included 12 patients with sustained ISDN therapy. Before and during administration of sublingual ISDN in both groups, aortic systolic pressure, left ventricular end-diastolic pressure and coronary artery diameter were examined at cardiac catheterization. During sublingual ISDN, the aortic systolic pressure decreased by 20 +/- 6% (138 +/- 26 to 112 +/- 27 mm Hg, p less than 0.01) in group C and 10 +/- 6% (127 +/- 26 to 113 +/- 23 mm Hg, p less than 0.01) in group N (p less than 0.01, group C vs group N). The left ventricular end-diastolic pressure decreased by 65 +/- 16% (11 +/- 5 to 4 +/- 3 mm Hg, p less than 0.01) in group C and 43 +/- 14% (12 +/- 5 to 7 +/- 3 mm Hg, p less than 0.01) in group N (p less than 0.01, group C vs group N). During sublingual ISDN, the diameters of the proximal and distal segments of the left anterior descending and circumflex coronary arteries increased more significantly in group C than in group N (p less than 0.01, group C vs group N). Thus, sublingual ISDN produced less reduction of aortic systolic pressure and left ventricular end-diastolic pressure, and less dilation of coronary artery diameter in patients receiving sustained therapy with ISDN than in those without sustained therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of sublingual nitroglycerin in patients receiving transdermal nitroglycerin for coronary artery disease: prevention of cross-tolerance.

The systemic hemodynamic and coronary dilative responses to sublingual nitroglycerin were studied in patients receiving transdermal nitroglycerin. A total of 48 patients with coronary artery disease were divided into 4 groups: 12 patients receiving 1 tablet of sublingual nitroglycerin without transdermal nitroglycerin (Group 1), 12 patients receiving 1 tablet of sublingual nitroglycerin with 12-hour-daily intermittent therapy of transdermal nitroglycerin (Group 2), 12 patients receiving 1 tablet of sublingual nitroglycerin with continuous therapy of transdermal nitroglycerin with continuous therapy of transdermal nitroglycerin (Group 3), and 12 patients receiving 2 tablets of sublingual nitroglycerin with continuous therapy of transdermal nitroglycerin (Group 4). Before and during administration of sublingual nitroglycerin, aortic pressure, left ventricular pressure, and coronary artery diameter were examined at diagnostic cardiac catheterization in all patients. During sublingual nitroglycerin, the decreases of aortic systolic pressure and left ventricular end-diastolic pressure were greater in Group 1, 2, and 4 than in Group 3. Dilation of coronary arteries by sublingual nitroglycerin tended to be greater in Group 1, 2, and 4 than in Group 3. Thus, the effects of sublingual nitroglycerin for the relief of ischemia might be more prominent in patients with intermittent therapy of transdermal nitroglycerin than in those with continuous therapy. The increased dose of sublingual nitroglycerin for the relief of ischemia might be more effective in patients with continuous therapy of transdermal nitroglycerin.

Coronary spasm producing coronary thrombosis in a patient with acute myocardial infarction.

A 62-year-old man had an acute myocardial infarction with successful thrombolysis. Coronary spasm was documented in the following angiographic study. This case demonstrated that coronary spasm is implicated in the pathogenesis of coronary thrombosis and subsequent myocardial infarction.

Differences of intravenous nitroglycerin responses in left ventricular systolic and end-diastolic pressures and coronary artery diameters during long-term treatment with cutaneous nitroglycerin patches.

The differences of intravenous nitroglycerin responses in left ventricular (LV) systolic and end-diastolic pressures and in coronary artery diameters (cross-tolerance) were investigated in patients receiving nitroglycerin patches. During diagnostic cardiac catheterization, graded doses of 50, 100, and 150 mcg of intravenous nitroglycerin were given. Left ventricular systolic and end-diastolic pressures and left coronary arteriograms were obtained during each dose. Twenty patients with coronary artery disease were studied. Before cardiac catheterization, 10 received nitroglycerin patch (patch group), and 10 did not (control group). In the control group, graded intravenous nitroglycerin doses of 50, 100, and 150 mcg caused decrease in LV systolic pressure of 18 +/- 7%, 20 +/- 5%, and 23 +/- 6%, respectively. In the patch group, the same intravenous nitroglycerin doses decreased LV systolic pressure by 12 +/- 6% (p < 0.05), 19 +/- 7% (NS), and 18 +/- 6% (p < 0.05), respectively, (p value: vs. control group). At the same intravenous nitroglycerin doses, LV end-diastolic pressures were decreased by 48 +/- 14%, 52 +/- 17%, and 56 +/- 9%, respectively, in the control group. However, there were no significant differences in LV end-diastolic pressure between the two groups for any of the three intravenous nitroglycerin doses. The same intravenous nitroglycerin doses caused increase in diameter of the left anterior descending coronary artery and circumflex coronary artery in the control group, which was attenuated significantly in the patch group. Tolerance may develop in LV systolic pressure and coronary artery diameters, whereas it may not develop in LV end-diastolic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Systolic time intervals by intratracheal pneumocardiogram and the effects of inhalation anesthetics on cardiac function using this technic].

Intratracheal pressure change due to cardiogenic oscillation was obtained by a high gain pressure transducer attached to the endotracheal tube while the patient was apneic during the operation. Such pressure change has been called as intratracheal pneumocardiogram (ITCG), which consists of wide waves and some spikes. Systolic time interval (STI) was obtained by measuring the intervals between certain spikes. The STIs measured by ITCG were compared with those by echocardiogram and by the conventional method. Also the effects of halothane, enflurane and isoflurane on cardiac performance were evaluated using the STI by ITCG. The STI measured by ITCG correlated well with that by echocardiogram, which indicated that the STI by ITCG was a useful noninvasive method to monitor the cardiac performance during general anesthesia. The STI by ITCG showed that the left ventricular ejection time (LVET) decreased in halothane and enflurane anesthesia. The pre-ejection period (PEP) and the PEP/LVET ratio increased in all three types of anesthesia. Especially the PEPs during halothane and enflurane at 1.8 MAC (minimum alveolar concentration) were greater than that of isoflurane. The results suggest that isoflurane has less cardiac depressive action than halothane and enflurane.

[Pediatric fiberoptic bronchoscopy via the laryngeal mask airway].

Fiberoptic bronchoscopy was performed on 11 children aged from 6 months to 3 years and weighing between 2.1 and 12.5 kg using the laryngeal mask airway (LMA). The LMA allows observation of subglottic stenosis which can not be seen under tracheal intubation. The smaller prototype of the fiberoptic bronchoscope whose diameter is 1.8mm has no provision for angulation at the tip. However, using the LMA as a guide it was easy to reach the subglottic stenosis even using this smaller bronchoscope.

[Anesthetic management of a patient with Conradi's syndrome (chondrodysplasia punctata)--a case report].

Conradi's syndrome is a rare hereditary disease characterized by punctate epiphyseal calcifications. The symptoms include short stature, typical facies with hypertelorism, saddle nose, short neck, tracheal stenosis and scoliosis. The deformities of airway and thoracic cage are expected to bring about ventilatory failure during anesthesia and operation. Although there has been a brief report of a death of a child with this syndrome during induction of anesthesia, we cannot find any other report concerning the perioperative respiratory management. This is a report on a girl with Conradi's disease who developed respiratory problems due possibly to gastric aspiration during ophthalmic surgery under general anesthesia. Several anesthetic problems raised by this case are discussed.

[Effect of enflurane and halothane on hemodynamics during the induction of anesthesia].

The effects of enflurane (E) and halothane (H) on hemodynamics were studied during the inhalation of 2MAC of each anesthetic before the surgery. Mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), systemic vascular resistance (SVRI) and stroke volume index (SVI) were measured noninvasively using automatic blood pressure manometer and ultrasonic Doppler method (Accucom). MAP decreased with both E and H, but the decrement was bigger with E. CI and SVI decreased with H, although increased with E. SVRI was unchanged with H, but decreased with E. These results indicate that enflurane causes the depression of blood pressure mostly by the decrease of afterload during the induction of anesthesia.

[Clinical evaluation of the laryngeal mask airway using capnogram].

The laryngeal mask airway (LMA) was clinically evaluated using capnogram in patients who breathed spontaneously under the combination of general and spinal anesthesia. Using the LMA, the airway was maintained without jaw lift and no remarkable hemodynamic change was observed during its insertion and removal. Capnogram was useful to confirm the intact airway and to monitor the respiration. Respiratory depression was observed after thiopental administration and enflurane inhalation. The respiration recovered promptly following the increase of respiratory rate (RR) and tidal volume at first, and it made a further recovery following increase in RR. The use of the LMA under light inhalation anesthesia is hence a useful combination with regional anesthesia.

[Anesthetic management of the patient with a permanent pacemaker].

Anesthetic management of two patients with a permanent pacemaker is reported; patient no. 1 had the VVI mode pacemaker and patient no. 2 had the DDD mode pacemaker. In patient no. 1, the hypotensive response of the 'pacemaker syndrome' occurred during general anesthesia. Patient no. 2 had no anesthetic problems but careful attention should be paid to the DDD mode pacemaker, because the newer widely used dual lead systems (DDD) are more susceptible to electromagnetic interference. Anesthetists often encounter patients with pacemakers. Knowledge of pacemakers available of the increasingly wide range is necessary to ensure safe management of these patients, many of whom are frail and elderly.

[Effects of sevoflurane on hemodynamics during the induction of anesthesia compared with those of isoflurane, enflurane and halothane].

The effects of sevoflurane (S), isoflurane (I), enflurane (E) and halothane (H) on hemodynamics were studied in 50 patients during the inhalation of 1.5 MAC of each anesthetic before the surgery. Mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and stroke volume index (SVI) were measured noninvasively using the automatic blood pressure manometer and the ultrasonic Doppler method (Accucom). There were significant differences between E and H in MAP, CI, SVRI and SVI. The values of CI, SVRI, SVI with S, as well as with I, were between those of E and H. These results indicate that sevoflurane causes the depression of blood pressure mostly by decreasing afterload during the induction of anesthesia, although the decrement with sevoflurane, as well as that with isoflurane, is less than that with enflurane.

[Effect of isoflurane, enflurane and halothane on hemodynamics during the induction of anesthesia].

The effects of isoflurane(I), halothane(H) and enflurane(E) on hemodynamics of 36 patients (12, 11 and 13, respectively) were studied during the inhalation of 1.5 MAC of each anesthetics before the surgery. Mean arterial pressure(MAP), heart rate(HR), cardiac index(CI), systemic vascular resistance index(SVRI), and stroke volume index (SVI) were measured noninvasively using the automatic blood pressure manometer and the ultrasonic Doppler method (Accucom). MAP decreased with I, E and H, but a larger decrement was observed with E than with H. CI and SVI with H were less than with E. SVRI decreased with I and E but a significant difference was observed between E and H. Each value with I was between those with H and E. These results indicate that isoflurane causes the depression of blood pressure mostly by its effect to decrease afterload during the induction of anesthesia, although its depressing effect is less than that of enflurane.

[A new method for endotracheal intubation with the Bullard laryngoscope].

The Bullard laryngoscope is an anatomically shaped rigid fiber optic instrument designed for indirect laryngoscopy and intubation. It requires no neck extension nor flexion to perform laryngeal intubation. This characteristic is especially useful in the case of difficult airway. The Bullard laryngoscope, however, with which it is easy to visualize the cords, has not been popular yet, because using the intubating forceps mechanism requires a certain amount of skill. The intubation method developed by us with Bullard laryngoscope has been tried on 26 patients with difficult airway and ten patients with normal airway. An endotracheal tube is inserted through nostril, and intubation is performed viewing the tube and larynx during all the processes of intubation. Three kinds of endotracheal tubes, i.e. Magill type plain tubes, styletted tubes, and directional tip tubes, are compared. The method using a directional tip tube (Endotrol) is concluded as the best among them. The Endotrol tube itself has such a suitable shape for nasal intubation that it can be introduced to the larynx with little directional change. Therefore, our method is mastered with a shorter training period than the intubation method with fiber-optic laryngoscopes. In conclusion, our intubation method with the Bullard laryngoscopes using the directional tip tubes (Endotrol) is useful for patients with difficult airways, and is also nontraumatic and easy to perform.

[Recurrent angina due to high grade re-stenosis of the left subclavian artery after coronary artery bypass grafting in a patient on hemodialysis for chronic renal failure: report of a case].

A 49-year-old woman on hemodialysis for chronic renal failure was admitted to our hospital with chest pain. She had undergone quadruple coronary artery bypass grafting (CABG) including a left internal thoracic to left anterior descending coronary artery anastomosis 9 months earlier. The blood flow through the left internal thoracic artery had decreased due to high grade stenosis at the proximal portion of the left subclavian artery, and recurrent angina had developed. She was treated by the placement of Palmaz biliary stents in the left subclavian artery, but re-stenosis occurred after 9 months, causing recurrent angina again. There fore, an operation was proposed and bypass grafting from the descending aorta to the left subclavian artery was successfully performed, resulting in complete resolution of her recurrent angina. This case serves to reinforce that patients on dialysis must be carefully followed up after CABG.

Echocardiographic estimation of forward stroke volume and mitral regurgitant volume in patients with or without left ventricular dyssynergy.

In order to estimate forward stroke volume (FSV) and mitral regurgitant volume (MRV) by echocardiography, the relationship between FSV or the severity of mitral regurgitation (MR) determined by conventional methods and those measured by aortic-left atrial echogram was investigated in 119 subjects, consisting of 88 patients without MR (no-MR group) and 31 patients with MR (MR group). The most adequate echocardiographic measurement for estimating FSV in the no-MR group was the product of posterior aortic wall excursion (Ao-PWE) and left atrial dimension (LAD); i.e., Ao-PWE X LAD. Further sophistication in estimating FSV was achieved by separating the subjects with LAD smaller than or equal to 40 mm from those with LAD > 40 mm. MRV was estimated by subtracting the FSV determined directly by either Fick or thermodilution method from the stroke volume determined by echocardiography. MRV so obtained was compatible with the severity of MR determined by LV cineangiography. The FSV in the no-MR group and the MRV in the MR group could be estimated with reliable accuracy by echocardiography alone (in the former) and by echocardiography plus a simple procedure such as Fick or thermodilution method (in the latter). Furthermore, this method was found to be free of influence from left ventricular dyssynergy or aortic regurgitation.

Does increasing end-tidal carbon dioxide during laparoscopic cholecystectomy matter?

To examine the adverse effects of peritoneal carbon dioxide (CO2) insufflation during laparoscopic cholecystectomy, both hemodynamic and respiratory alterations were continously monitored in 17 adult patients using noninvasive Doppler ultrasonography and a continuous spirometric monitoring device. During the surgery, which was performed under inhalational general anesthesia, intraabdominal pressure was maintained automatically at 10mmHg by a CO2 insufflator, and a constant minute ventilation, initially set to 30-33 mmHg of end-tidal CO2 (ETCO2), was maintained. Despite considerable depth of anesthesia, peritoneal CO2 insufflation induced a significant and immediate increase of mean blood pressure (+42%) and systemic vascular resistance (+62%), accompanied by a slight depression of cardiac index (-12%, nonsignificant), while the ETCO2 gradually increased and maximized around 30min following the initial CO2 insufflation. The stress of 10mmHg pneumoperitoneum was a major cause of hemodynamic changes during laparoscopic cholecystectomy. Some clinical strategies such as deliberate intraabdominal insufflation at the initial phase might be required to minimize these hemodynamic changes.

Nasal intubation with Bullard laryngoscope: a useful approach for difficult airways.

Since the original technique using the Bullard laryngoscope requires considerable practice to be reliable, we have developed an easier method with a directional-tip endotracheal tube through the nostril. We first examined the feasibility of our method in patients with or without difficult airways. All 26 patients with difficult airways were successfully tracheally intubated with our method, and times for visualization and intubation were not different from those in 10 patients with normal airways. We further examined the direction of the tips of endotracheal tubes through the nostril in 128 patients with normal airways using four combinations of two kinds of both laryngoscopes (Bullard and Macintosh) and endotracheal tubes (directional-tip tube: Endotrol, Mallinckrodt Laboratories, Athlone, Ireland; or straight distal-end tube: Blue Line, Portex Ltd., Hythe Kent, United Kingdom). We found that a combination of the Bullard laryngoscope and the Endotrol tube had a higher probability of accessing the center of the glottis than the others. In conclusion, nasal insertion of a directional-tip tube assisted by the Bullard laryngoscope is an assured and prompt procedure for intubating the tracheas of patients with difficult airways.

Epidural anesthesia during upper abdominal surgery provides better postoperative analgesia.

Since repeated noxious stimuli may sensitize neuropathic pain receptors of the spinal cord, we tested the hypothesis that the appropriate blockade of surgical stimuli with epidural anesthesia during upper abdominal surgery would be beneficial for postoperative analgesia. Thirty-six adult patients undergoing either elective gastrectomy or open cholecystectomy were randomly allocated to receive either inhalational general anesthesia alone (group G) or epidural anesthesia along with light general anesthesia (group E) throughout the surgery. Postoperative pain management consisted of patient-controlled analgesia (PCA) with bupivacaine accompanied by the continuous infusion of buprenorphine. To assess postoperative pain, a visual analogue scale (VAS) was employed at 2, 24, and 48 h postoperatively. While there was no significant difference in the bupivacaine dose, more patients undergoing gastrectomy in group G required supplemental analgesics than those in group E, and the VAS scores in group E demonstrated significantly better postoperative analgesia compared to group G after both types of surgery. Thus, an appropriate epidural blockade during upper abdominal surgery likely provides better postoperative pain relief.

[Congenital anomalies of the coronary arteries with associated ischemic ST depression on exercise: a report of three cases].

This report presented evidence of myocardial ischemia as the etiology of angina pectoris in three patients with congenital anomalies of the coronary arteries but without arteriosclerotic disease. All of three cases showed angina pectoris and ST depressions on their exercise electrocardiogram. Case 1: This 58-year-old man developed angina pectoris at the age of 50 years. His treadmill exercise test precipitated chest pain and ST depression. His coronary arteriograms disclosed an ectopic origin of the right coronary artery just anterior to the origin of the left coronary artery in the left coronary sinus. No significant atherosclerotic stenosis was present. An apparent ischemic manifestation appeared to be caused by compression of an aberrant right coronary artery between the aorta and the right ventricular infundibulum. Case 2: A 49-year-old woman had a history of angina. Her treadmill exercise test induced chest pain and an abnormal exercise electrocardiographic finding. Her coronary arteriograms revealed a single left coronary artery. Insufficient perfusion was postulated as a cause of apparent myocardial ischemia in this case though angiographically, there was adequate perfusion. Case 3: This 31-year-old man had a six-year history of angina. His treadmill exercise electrocardiograms revealed ischemic changes accompanied by chest pain. Coronary arteriograms disclosed a coronary artery fistula. The ischemic manifestation was apparently caused by inadequate perfusion due to coronary steal. With the increasing use of coronary arteriography, unusual origins and courses of coronary arteries will be more frequently encountered. Precise knowledge of anomalies is prerequisite for evaluating variations in the location of the coronary artery ostia and their statistical probabilities.