Papillary muscle sandwich plasty for the treatment of functional mitral valve regurgitation.

We evaluated the availability of original "sandwich plasty" for the treatment of functional mitral regurgitation (FMR) associated with ischemic heart disease (IHD) and aortic valve disease (AVD). Forty-three patients were reviewed, including 27 IHD patients and 16 AVD patients. Preoperatively severe FMR was detected in 14 patients, moderate FMR in 26, and mild FMR in 3. The papillary muscle heads of anterior leaflets and posterior leaflets were approximated using Teflon-pledgeted 3-0 Ticron sutures at anterolateral and posteromedial commissural portions. After surgery, residual moderate FMR was observed in 1 patient and mild FMR in 3 patients. Tenting height of the mitral valve significantly decreased. FMR free rates 2 years after surgery were 93% among IHD patients and 83% in AVD patients. "Sandwich plasty" was simple and effective for the treatment of functional FMR caused by tethering effects due to left ventricular dilatation.

[Choice of induction with, or standby of, extracorporeal lung assist (ECLA) in anesthetic management of bronchoscopic yttrium-aluminium-garnet (YAG) laser treatment of airway tumor].

Bronchoscopy with an yttrium-aluminium-garnet (YAG) laser is often used to resect benign and malignant airway tumors and for relief of associated airway stenosis. Complications of this procedure include airway obstruction and hemorrhage. Partial extracorporeal circulation for YAG laser resection in the airway may be helpful in minimizing these complications. Extracorporeal lung assist (ECLA) should be available for such bronchoscopic surgery, although it is not always required. We managed the general anesthesia for bronchoscopic YAG laser resection of airway tumors in two patients. The first case was a 60-year-old man with a right bronchial tumor that had invaded into the trachea across the carina. The narrowest inner diameter of the part of the trachea affected by the lesion was 3 mm. ECLA was initiated for a bronchoscopic YAG laser resection. The second case was a 74-year-old woman with a metastastic lung tumor from osteosarcoma. The narrowest inner diameter of the lesion in the right truncus intermedius was 4 mm. ECLA was kept on standby for possible complications in the bronchoscopic YAG laser resection. These treatments were completed successfully in both patients without any adverse events. ECLA is a useful supporting technique for performing bronchoscopic YAG laser treatment safely ECLA is recommended where a bronchial lesion invades the trachea and crosses the carina, and where a tracheal lesion will not allow passage of a tracheal tube under the bronchoscope. However, ECLA may be kept on standby for a airway tumor limited to one main bronchus, and for a peripheral bronchial lesion, and even for an invasive tracheal lesion through which the tracheal tube under the bronchoscope can pass. Whether it is used or kept on standby depends on the location and severity of airway compromise caused by the airway lesions.

[Intravenous patient-controlled analgesia (IV-PCA) for relief of postoperative pain].

Intravenous patient-controlled analgesia (IV-PCA) using opioids such as morphine and fentanyl can be an effective analgesic method for post-operative pain that is resistant to conventional administration of narcotic analgesics and nonsteroidal anti-inflammatory drugs, and where epidural block and peripheral nerve block are not feasible. In addition to post-operative pain relief, IV-PCA can facilitate early ambulation, reduce respiratory complications, and increase patient satis-faction. However, respiratory and circulatory depression, and post-operative nausea and vomiting (PONV) often occur as side effects of IV-PCA with opioids. Administration of droperidol can be an effective treatment for PON.

[Femoral and sciatic nerve blocks for open reduction and internal fixation of a femoral condylar fracture in a patient with post-polio syndrome].

The post polio symdrome (PPS) refers to the development of delayed neuromuscular symptoms among survivors, years after the initial presentation of acute poliomyelitis. The symptoms of PPS vary widely and include flaccid palsy, muscle weakness, scoliosis, osteoarthritis, gait disturbance, sleep apnea syndrome (SAS), dysphagia, chronic lung dysfunction, and others. We report the successful combination of peripheral nerve blocks, femoral and sciatic nerve blocks, for surgery on the lower extremity in a patient with PPS. A 51-year-old man with continuous positive airway pressure therapy for restrictive ventilatory impairment due to scoliosis and SAS as part of the PPS was scheduled for open reduction and internal fixation (OR-IF) for a right femoral condylar fracture. Respiratory function tests demonstrated a vital capacity (VC) 1.41l (41% predicted). Arterial blood gas analysis on room air was; pH 7.376, PaCO2 55.0 mmHg, and PaO2 77.9 mmHg. With the patient in the supine position, ultrasound-guided right femoral nerve block in the infra-inguinal region was performed using 1.5% mepivacaine 10 ml and 0.75% ropivacaine 5 ml, followed by sciatic nerve block in the popliteal fossa using 1.5% mepivacaine 8 ml and 0.75% ropivacaine 4 ml in the prone position. OR-IF of the fractured femoral condyle was then successfully performed with propofol under spontaneous ventilation. Postoperatively, there were no adverse events; respiratory function was adequate, and his pain was within manageable bounds. Femoral and sciatic nerve blocks are safe and effective anesthetic methods for lower extremity surgery in patients with restrictive ventilatory impairment and hypercapnia due to scoliosis and SAS as PPS.

[Experience of participating in the 14th Nepal Cleft Lip and Palate Surgery Project].

Adventist Development and Relief Agency (ADRA) Japan, a non governmental organization (NGO), following an official request of Federal Democratic Republic of Nepal Government has organized Nepal Cleft Lip and Palate Surgery Project since 1995. We participated in the 14th Project as one of the anesthesiologists from 7th to 22nd November 2009 and performed general anesthesia with a Nepalese anesthetist without a medical license in Sheer Memorial Hospital. Use of unfamiliar anesthetic medications and limited medical devices made us understand the difficulty of anesthetic management. This valuable anesthetic experience will be useful for us in general anesthetic management in the future.

[Effect sites of anesthetics in the central nervous system network--looking into the mechanisms for natural sleep and anesthesia].

We showed the effect sites of anesthetics in the central nervous system (CNS) network. The thalamus is a key factor for loss of consciousness during natural sleep and anesthesia. Although the linkages among neurons within the CNS network in natural sleep are complicated, but sophisticated, the sleep mechanism has been gradually unraveled. Anesthesia disrupts the link-ages between cortical and thalamic neurons and among the cortical neurons, and thus it loses the integration of information derived from the arousal and sleep nuclei. It has been considered that anesthesia does not share the common pathway as natural sleep at the level of unconsciousness, because anesthetics have multiple effect sites within CNS network and may induce disintegration among neurons. Recent literatures have shown that the effects of anesthetics are specific rather than global in the brain. It is interesting to note that thalamic injection of anti-potassium channel materials restored consciousness during inhalation anesthesia, and that the sedative components of certain intravenous anesthesia may share the same pathway as natural sleep. To explore the sensitivity and susceptibility loci for anesthetics in the thalamocortical neurons as well as arousal and sleep nuclei within CNS network may be an important task for future study.

[Predisposing factors and prevention of emergence agitation].

Agitation during the emergence from general anesthesia is a great post-operative problem that often injures the patients themselves and requires the medical staff to restrain and calm the patients. The predisposing factors for emergence agitation include anesthesia, operation, and patient. Sevoflurane anesthesia results in higher incidence of emergence agitation than halothane, because of the rapid emergence, and its effects on central nervous system inducing convulsion and post-operative behavioral changes. The otorhinolaryngologic and ophthalmologic surgeries, post-operative pain, young age, pre-operative anxiety, no past surgical history, and adjustment disorder of patients are risk factors for emergence agitation. The change from sevoflurane to propofol during anesthesia maintenance is a contributing factor to reduce incidence of emergence agitation. The medications including opioids, midazolam, alpha-2 agonists, ketamine, non-steroidal anti-inflammatory drugs, nitrous oxide, and propofol, and aggressive nerve block such as caudal epidural block for post-operative sedation and analgesia are effective to avoid incidence of emergence agitation. The calm emergence following general anesthesia would decrease the self-injuring behavior, and enhance the parent and caregiver satisfaction in general anesthesia and surgery.

Efficacy of amiodarone on refractory ventricular fibrillation resistant to lidocaine and cardioversion during weaning from cardiopulmonary bypass in aortic valve replacement for severe aortic stenosis with left ventricular hypertrophy.

Intravenous injection of amiodarone, a class III anti-arrhythmic is widely used for persistent refractory arrhythmias. We present a case report suggesting the efficacy of amiodarone in refractory ventricular fibrillation (Vf) during weaning from cardiopulmonary bypass (CPB). A 66-year-old woman with hypertension had a medical examination as a result of an episode of palpitations and syncope. Echocardiography and an invasive hemodynamic study revealed severe aortic stenosis (AS) with left ventricular (LV) hypertrophy because of calcified degeneration in a congenital bicuspid aortic valve (AV). Aortic valve replacement (AVR) was scheduled under general anesthesia and CPB. Intraoperative diagnosis was AS with calcified AV, LV hypertrophy, and aneurysm of ascending aorta (Ao). AVR with a biological valve, artificial vessel replacement of ascending Ao, and excision of the outflow myocardial septum were performed under CPB with intermittent antegrade blood cardioplegia at a body temperature (BT) of 24°C. The patient suffered from Vf at a BT of 35.3°C. Vf was not responsive to lidocaine 100 mg and 10 direct current (DC) shocks. After continuous intravenous infusion of amiodarone 225 mg/h for 10 min and a single intravenous injection of amiodarone 150 mg followed by a single DC shock, she returned to normal sinus rhythm. Sinus rhythm was maintained by continuous intravenous infusion of amiodarone 60 mg/h. Total CPB time was 5 h 43 min. Aortic cross-clamping time was 3 h 50 min. Administration of amiodarone is effective for refractory Vf resistant to lidocaine and cardioversion during weaning from CPB in cardiac surgery for heart diseases with LV hypertrophy.

[Awake fiberoptic intubation with Parker Flex-Tip tracheal tube in a patient with obesity, goiter, and laryngo-tracheal shift].

A 59-year-old woman with a body mass index of 30 and an edematous, tender goiter was scheduled for subtotal thyroidectomy. She had a history of dyspnea, cough, hoarseness, sleep disturbance in the supine position, difficulty in expelling sputum, and inability to rotate her neck to the left. Chest CT showed an adenomatous goiter, measuring 42 x 57 x 105 mm, with invasion into the mediastinal space, 17 mm right glottic shift, and 21 mm right tracheal shift. Because of her goiter and laryngo-tracheal shift, we anticipated a difficult intubation and ventilation. Awake fiberoptic intubation was selected for anesthesia induction, and was easily performed using a Parker Flex-Tip tracheal tube (Parker Medical, Highland Ranch, Colorado, USA), after intravenous injection of 200 microg of fentanyl, 8% lidocaine pump spray on the larynx with a direct laryngoscope, and 5 ml of 4% lidocaine spray on the vocal cords and trachea through a bronchoscope. The operation was completed successfully without any adverse events. Awake fiberoptic intubation with a Parker Flex-Tip tracheal tube is easily performed in a patient with a difficult airway due to obesity, goiter, and laryngo-tracheal shift.

[Tracheal intubation in patients with Williams syndrome].

Williams syndrome is caused by the deletion of genetic material from chromosome 7, including the elastin gene. Affected individuals frequently have connective tissue disorders and skeletal hypoplasia, resulting in micrognathia and mandibular retrusion. These conditions hinder adequate visualization of the larynx and render intubation difficult. We used different methods of tracheal intubation for two patients with Williams syndrome. The first case was a 35-year-old woman with micrognathia, mandibular retrusion, and a Mallampati class III airway, scheduled for mitral valve replacement. She had a three fingerbreadth oral aperture, 3.0 cm mandibulohyoid distance, and 30 degree neck flexion. Since she had previously been successfully intubated at age 18 for patch enlargement of the aorta and extended aortoplasty, we elected to use intravenous anesthetic agents for this intubation. After administration of diazepam and fentanyl, mask ventilation was difficult and the direct laryngoscopic view was Cormack grade IV. Fortunately, blind orotracheal intubation using a Mallinckrodt tracheal tube with direct laryngoscopy was accomplished on the first attempt. The second case was a 71-year-old woman with micrognathia, slight mandibular retrusion, macroglossia, and a Mallampati class IV airway, scheduled for sigmoidectomy and insertion of a ureteral stent. She had a 2.5 fingerbreadth oral aperture, 4.0 cm mandibulohyoid distance, and 30 degree neck flexion. From our experience with the first patient, we expected difficult ventilation and intubation. After 8% lidocaine spray to the larynx, and then 4% lidocaine spray to the vocal cords and trachea using a bronchoscope, we accomplished awake, fibreoptic-guided orotracheal intubation easily and quickly on the first attempt using a Parker Flex-Tip tube. Difficult tracheal intubation should be anticipated in Williams syndrome patients. Awake, fibreoptic-guided technique is easier and safer than direct laryngoscopy for intubating such patients.

Microinjection of propofol into the perifornical area induces sedation with decreasing cortical acetylcholine release in rats.

BACKGROUND: Among many neurotransmitter systems in the central nervous system, the cholinergic system has been shown to contribute to propofol's sedative/anesthetic effects, because it has been shown that cholinesterase inhibitor reverses the level of propofol-induced unconsciousness in humans. It has been reported that intraperitoneal injection of propofol induced sedative/anesthetic actions and decreased the release of acetylcholine (Ach) from the rat cortex. However, the sites of action of propofol in the cholinergic pathway and its related pathways remain unresolved. We studied whether microinjection of propofol into the nuclei in the cholinergic pathway and its related pathways may induce sedation and decrease Ach from the cortex. METHODS: Thirty-seven male Wistar rats weighing 270 to 320 g were used. Almost 5 days before the experiments, 23 rats anesthetized with pentobarbital (50 mg/kg) were outfitted with an electroencephalogram (EEG) socket, a microdialysis cannula in the cortex, and an intraperitoneal tube or a microinjection tube into the basal forebrain (BF), the perifornical area (Pef), or the striatum. The Ach effluxes in the somatosensory cortex were detected using in vivo intracerebral microdialysis in freely moving rats. Once basal levels of Ach were stabilized, samples were collected every 20 minutes and measured by high-performance liquid chromatography. In the intraperitoneal group, propofol was cumulatively administered (10, 30, and 100 mg/kg) into the peritoneal cavity. In the microinjection groups, propofol (40 ng in 0.2 microL) was administered into the BF, the Pef, or the striatum (control), and the cortical changes in Ach efflux and EEG were observed for 2 hours. In another 14 rats, the sedative/anesthetic score was obtained after intraperitoneal, Pef, or striatal injection of propofol. The placement of the tip of the microdialysis probe and the microinjection tube was confirmed by histological examination. RESULTS: Intraperitoneal injection of propofol dose-dependently decreased the Ach efflux and induced light sedative to moderate anesthetic states. Loss of righting reflex was observed with significant increases in the relative alpha-power band at 100 mg/kg propofol. Microinjection of propofol into the BF significantly decreased the cortical Ach efflux to -40.2% + or - 19.9% at 40 to 60 minutes. However, there was no difference in the total Ach efflux for 2 hours between BF and control groups. In contrast, microinjection of propofol into the Pef immediately decreased the Ach efflux at 0 to 20 min and maximally to -59.3 + or - 20.4 at 100 to 120 minutes. The total Ach efflux in the Pef microinjection group was significantly less than that in the control group. The same dose of propofol injected into the Pef induced light to deep sedation. There was no significant change in the relative EEG power band between BF or Pef and control groups. CONCLUSION: The nuclei in the Pef are, at least in part, responsible for the sedative action of propofol in rats.

[Evaluation of cardiac and myocardial inotropism and lusitropism using half-logistic curve-fitting].

Half-logistic (h-L) function, which is half of the sigmoidal, logistic function with a boundary at the inflection point, curve-fits the isovolumic relaxation left ventricular (LV) pressure curve from the minimum of the first order time derivative of pressure (dP/dt(min)), and the myocardial isometric relaxation tension curve from the minimum of the first order time derivative of tension (dF/dt(min)) superior to the conventional mono-exponential function. Recently, we found that h-L function could curve-fit the other partial curves. The isovolumic LV pressure curve in the excised, cross-circulated canine heart, was divided into four distinct phases with boundaries set at the maximum of dP/dt (dP/dt(max)), peak LV pressure, dP/dt(min), and LV end-diastolic pressure (LVEDP) resulting in the first phase from the point corresponding to QR on the electrocardiogram to dP/dt(max); the second phase from dP/dt(max) to the peak LV pressure; the third phase from the peak LV pressure to dP/dt(min); and the fourth phase from dP/dt(min) to LVEDP. Similarly, the isometric twitch tension curves in the mouse LV and rabbit right ventricular (RV) papillary muscles were divided into four distinct phases with boundaries set at the maximum of dF/dt (dF/dt(max)), peak tension, dF/dt(min), and resting tension resulting in the first phase from the point corresponding to twitch stimulation to dF/dt(max); the second phase from dF/dt(max) to the peak tension; the third phase from the peak tension to dF/dt(min); and the fourth phase from dF/dt(min) to resting tension. The h-L correlation coefficient (r) values for the sequential curves were larger than the m-E r values, respectively, and the h-L residual mean squares (RMS) were smaller than the m-E RMS values, respectively. The h-L time constants are indices which quantify cardiac and myocardial inotropism and lusitropism more accurately. We consider that the h-L approach also applies for evaluation of the isovolumic contraction phase and the isovolumic relaxation phase in the beating hearts.

[Tracheal intubation with Parker Flex-Tip tubes assisted by tube-guiding devices].

In tracheal intubation assisted by tube-guiding devices passing through the tube, such as fiberoptic scopes, bougies, tracheal tube exchange catheters, and light wands, passage of the tube-guiding device, by itself, is often easy. But advancing a tracheal tube with a conventional distal tip over these tube-guiding devices is frequently difficult or impossible, because its rigid, side-beveled tip frequently catches on anatomical features of the airway. A novel tracheal tube, the Parker Flex-Tip tube (Parker Medical, Colorado, USA) has a centered, curved, tapered and flexible distal tip that passes through the airway faster and easier than conventional tracheal tubes. As it is advanced along a tube-guiding device, the tip of the Parker tube travels along the midline of the airway, without the gap that usually exists between the distal edge of a conventional tracheal tube and the tube-guiding device. The gapless, midline travel of the Parker tube leads to a greater incidence of first-attempt intubation success with tube-guiding devices, because there is less risk of tube tip hang-ups on the arytenoids and the vocal cords. Clinically, use of the Parker tube is helpful for oral and nasal intubations, especially in patients with difficult airways.

[Paracervical block for dilatation and curettage in a parturient with Eisenmenger's syndrome].

Eisenmenger's syndrome is defined as the process in which a left-to-right shunt due to an atrial (ASD) or ventricular septal defect (VSD) in the heart causes increased pulmonary blood flow, leading to pulmonary hypertension, which in turn, ultimately results in increased pressure in the right side of the heart and reversal of the shunt to right-to-left. Therefore, anesthetic management of Eisenmenger's syndrome is often difficult. We described a case of paracervical block for dilatation and curettage in a parturient with Eisenmenger's syndrome in this report. A 29-year-old woman with Eisenmenger's syndrome due to ASD became pregnant. She had dyspnea, cyanosis, and clubbed fingers. Her activity of daily life was in a wheel chair, and she was evaluated as New York Heart Association (NYHA) class IV. Her oxygen saturation by pulse oxymeter (Sp(O2)) showed 78-82% in room air. Dilatation and curettage was scheduled in the sixth week of her pregnancy. We performed paracervical block in the direction of 4 and 8 o'clock using 1% lidocaine 12 ml under 6 l x (min(-1) oxygen inhalation through a face mask. Seven minutes after the beginning of the operation, Sp(O2) temporarily decreased to 77% due to abdominal pain by surgical procedures. The operation was finished within 8 minutes. She had no adverse events postoperatively. The anesthetic goal for Eisenmenger's syndrome is to avoid hemodynamic changes that can worsen hypoxemia through an increase in right-to-left shunt. Paracervical block is safe and effective conduction anesthesia for dilatation and curettage in a parturient with Eisenmenger's syndrome.

[Clinical anesthetic training at St. Vincent's Hospital, Melbourne Australia].

Anesthesia training system and operation theater management at St Vincent's hospital Melbourne in Australia, are very well organized, including tutorials, invitation lecture, transesophageal echocardiography conference as well as working hour, operation room, organization of comedical staffs such as nursing and technician staff, and day surgery and anesthesia. Good anesthesia training system and efficient operation theater management are necessary to establish better quality of medical services.

[Perioperative management of a patient with Parkinson's disease with intravenous infusion of levodopa].

Parkinson's disease is a disorder of the extrapyramidal system resulting from the deficiency of dopamine in the basal ganglia. We experienced the perioperative management of a patient with Parkinson's disease with intravenous infusion of levodopa, precursor of which is dopamine. A 73-year-old woman with Parkinson's tremor in her bilateral fingers of Hoehn and Yahr stage II was scheduled for repair of bladder prolapse under general anesthesia. Antiparkinson drug levodopa/dopa decarboxylase inhibitor (carbidopa) 400 mg per day had been administered orally to control her bilateral tremor. Three hours before the operation, oral medication including levodopa/carbidopa 100 mg was withdrawn, and intravenous infusion of levodopa 100mg was started. Without any premedication, anesthesia was induced with intravenous infusion of propofol, fentanyl, and vecuronium, and tracheal intubation was facilitated. Anesthesia was maintained with inhalation of air, oxygen, and sevoflurane, and intravenous infusion of fentanyl. After emergence, we found no neurological disorders excluding her tremor. Levodopa/carbidopa 100 mg was readministered orally four hours after the operation and total of 300 mg had been administered orally on the operative day. Levodopa/carbidopa 400 mg per day had been administered orally after the first operative day. She did not show deterioration of her symptom of Parkinson's disease, and develop any complications during the perioperative period. We need to manage Parkinson's disease with intravenous infusion of levodopa during the perioperative period, taking care of the symptom of Parkinson's disease and the occurrence of complications.

[Intermittent bradycardia-dependent bundle branch block during sevoflurane and remifentanil anesthesia].

Cardiac arrhythmia and bradycardia occasionally occur from the effect of inhaled anesthetic agent and opioid on cardiac conduction. We experienced a case of intermittent bradycardia-dependent bundle branch block (IBDBBB) during sevoflurane and remifentanil anesthesia. A 17-year-old woman suffering from recurrent left ottitis media was scheduled for tympanoplasty under general anesthesia. Her preoperative electrocardiogram (ECG) revealed normal sinus rhythm at heart rate (HR) of 48 beats x min(-1). Her tracheal was intubated following anesthesia induction with propofol and vecuronium, and anesthesia was maintained using inhalation of 40% oxygen with air and 1.5-2.0% sevoflurane, and continuous venous infusion of remifentanil at a rate of 0.15 microg x kg(-1) min(-1). Two hours 20 minutes after starting operation, the P-P interval was constant but the waveforms of low and broad QRS complexes appeared intermittently on the ECG monitor. The blood pressure remained stable at 95/55 mmHg and the HR decreased to 46 beats x min(-1). The waveform of pulse oxymetric oxygen saturation (Spo2) did not change. We diagnosed the ECG pattern as IBDBBB. After intravenous injection of atropine 0.5 mg, the waveforms of QRS complexes recovered to normal sinus rhythm at HR 90 beats x min(-1). Sevoflurane and remifentanil in adolescence could induce ventricular conduction disturbance and result in IBDBBB. Atropine could be effective for IBDBBB induced by sevoflurane and remifentanil.

[Massive hemorrhage during abdominal total hysterectomy in a patient with placenta percreta].

A 33-year-old pregnant woman, who had undergone three previous cesarean sections and suspected of having placenta accrete, was scheduled for artificial abortion and abdominal total hysterectomy at 15 weeks gestation because of a probable high mortality rate. The general anesthesia was induced using fentanyl, propofol, and vecuronium and maintained with sevoflurane, fentanyl, and vecuronium, in combination with epidural anesthesia using ropivacaine. During the operation, we found that the placenta had penetrated into the posterior abdominal peritoneum and bladder wall. Sudden, massive hemorrhage was encountered when attempting to separate the placenta percreta. The massive hemorrhage, up to 11,054 ml, was controlled by transfusion, infusion, and temporary clamping of the bilateral common iliac arteries. Rapid infuser LEVEL1 and autologous blood recovery systems Electa were also used. After the surgery, the patient was transferred to the intensive care unit intubated and was discharged on the 16th posteroperative day without any complications. Anesthesiologists should be prepared for massive hemorrhage in cases of abdominal total hysterectomy with suspected placenta percreta.

[Anaesthesia training program in Australia].

We reviewed anaesthesia training program in Australia. Anaesthetists in Australia and New Zealand need to obtain the Diploma of Fellowship of the Australian and New Zealand College of Anaesthetists (FANZCA) to be recognised as specialists. The training sequence approved by ANZCA encompasses an initial two-year Prevocational Medical Education, Training (PMET) period, and the five-year period of ANZCA Approved Training, which included two-year Basic Training and three-year Advanced Training. On completion of all Training Program requirements the Trainee is awarded the Diploma of Fellowship and is entitled to use the qualification of FANZCA. The assessment of trainees in anaesthesia is principally by examination and the staff of the hospitals in which trainees work. There are a number of specific goals to be achieved during training. ANZCA accredits Hospital Departments of Anaesthesia and other training institutions across Australia, New Zealand, and South-East Asia, to provide approved training in anaesthesia for ANZCA trainees. Accreditation requires an onsite review by the College in order to assess a hospital's ability to provide training and supervision of the required standard, and its degree of compliance with ANZCA Professional Documents.

Half-logistic time constants as inotropic and lusitropic indices for four sequential phases of isometric tension curves in isolated rabbit and mouse papillary muscles.

The waveforms of myocardial tension and left ventricular (LV) pressure curves are useful for evaluating myocardial and LV performance, and especially for inotropism and lusitropism. Recently, we found that half-logistic (h-L) functions provide better fits for the two partial rising and two partial falling phases of the isovolumic LV pressure curve compared to mono-exponential (m-E) functions, and that the h-L time constants for the four sequential phases are superior inotropic and lusitropic indices compared to the m-E time constants. In the present study, we tested the hypothesis that the four sequential phases of the isometric tension curves in mammalian cardiac muscles could be curve-fitted accurately using h-L functions. The h-L and m-E curve-fits were compared for the four phases of the isometric twitch tension curves in 7 isolated rabbit right ventricular and 15 isolated mouse LV papillary muscles. The isometric tension curves were evaluated in the four temporal phases: from the beginning of twitch stimulation to the maximum of the first order time derivative of tension (dF/dt(max)) (Phase I), from dF/dt(max) to the peak tension (Phase II), from the peak tension to the minimum of the first order time derivative of tension (dF/dt(min)) (Phase III), and from dF/dt(min) to the resting tension (Phase IV). The mean h-L correlation coefficients (r) of 0.9958, 0.9996, 0.9995, and 0.9999 in rabbit and 0.9950, 0.9996, 0.9994, and 0.9997 in mouse for Phases I, II, III, and IV, respectively, were higher than the respective m-E r-values (P < 0.001). The h-L function quantifies the amplitudes and time courses of the two partial rising and two partial falling phases of the isometric tension curve, and the h-L time constants for the four partial phases serve as accurate and useful indices for estimation of inotropic and lusitropic effects.