Clinical experience with a sucking sump catheter in the treatment of esophageal atresia.

This is an introduction to the sucking sump catheter as a method of continuous salivary suction from the oral cavity for the treatment of esophageal atresia and other diseases. Upper pouch suction on many occasions is not easy. The double lumen catheter was devised by Replogle to achieve better suction efficiency, but this is not always satisfactory. Therefore, we devised an oral suction catheter that is a sucking sump catheter. A no. 8 French Argyle Salem sump catheter was transformed; we added five to six holes, and the tip was bent into a double or triple circle. This is sucked on, as a nipple would be, by the infant. From 6 years of experience, we have determined that this works very well for continuous salivary aspiration from the oral cavity, that it causes no complications; this device can also contribute to early oral feeding after esophageal anastomosis.

The need for a global health disaster network.

When a disaster occurs, a major difficulty is knowing where to find accurate information, and how to help coordinate efforts to share accurate information in a quick and organized manner. The establishment of a global information network, that is in place before a disaster occurs, could link all the communication efforts for relief. We propose that a Global Health Unit for Disaster and Relief Coordination be set up as part of the Global Health Network, utilizing the Internet as its backbone. This Unit would establish the links for the disaster information mosaic.

[Diltiazem potentiates the neuromuscular blockade by vecuronium in humans].

We investigated interaction of diltiazem with vecuronium using constant infusion technique in 24 ASA class I or II elective surgical patients with no preoperative administration of Ca antagonists. Neuromuscular blockade was evaluated with accelerometry, which measured single twitch height of adductor pollicis muscle. After tracheal intubation under isoflurane anesthesia, patients received either no diltiazem (control group, n = 8)m, 5 mg (bolus) + 2 mcg.kg-1.min-1 constant infusion (2 mcg group, n = 8) or 5 mg (bolus) + 4 mcg.kg-1.min-1 constant infusion (4 mcg group, n = 8). When single twitch height returned to 10% of control value, infusion of vecuronium was started and the infusion rate was adjusted to maintain twitch height at 10% of the control value. After 30 minutes of stable twitch height, the vecuronium infusion rate and plasma diltiazem concentrations were measured. Diltiazem infusion of 4 mcg.kg-1.min-1 decreased the vecuronium infusion rate by 45% compared with 2 other groups. Plasma diltiazem concentrations in patients receiving 4 mcg.kg-1.min-1 were significantly higher than those receiving 2 mcg.kg-1.min-1. In conclusion diltiazem 4 mcg.kg-1.min-1 potentiates the neuromuscular blockade of vecuronium and it relates with the plasma diltiazem concentration.

[Estimation of respiratory functions by analysis of expired gas and blood gas during artificial ventilation and general anesthesia].

One-hundred and seven patients undergoing elective surgery were studied to analyze the correlations between preoperative spirometric values and respiratory parameters during general anesthesia. They were grouped according to 3 criterions; preoperative %VC of less than 80%, FEV1.0% of less than 70%, V50/V25 exceeding 4.0. Following the induction of general anesthesia and of mechanical ventilation, expiratory flow (VE), FECO2, PaCO2 and PaO2 were measured to calculate respiratory parameters including VCO2-SR, VD/VT-Bohr, VD/VT-physiological (phys), a-ETDCO2, Volume Pressure Index (VPI) and A-aDO2. Six respiratory parameters were compared between the groups, and correlations between preoperative spirometric values were studied. Those with lower %VC had higher values in VCO2-SR and in VPI, and those with lower FEV1.0% had higher values in VCO2-SR, in VD/VT-phys and in a-ETDCO2. Significant correlations were also observed between these parameters. Preoperative V50/V25 and A-aDO2 during general anesthesia did not correlate with any of the parameters studied. We conclude that VCO2-SR, VD/VT-phys, a-ETDCO2 and VPI during general anesthesia are useful to detect the patients with restrictive and/or obstructive lung dysfunction, although they are not sensitive enough to detect those with small airway disease.

[Multiple regression analysis of pre- and intra-operative factors in relation to post-operative liver and renal functions].

We investigated the factors which may influence post-operative liver and renal function using a multiple regression analysis after isoflurane or sevoflurane anesthesia in 844 patients (ASA I or II, age 20-90 yr). Hepatic and renal surgeries were excluded from this study. The parameters examined were sex, age, degree of obesity, preoperative liver function, preoperative renal function, infection with hepatitis B or hepatitis C virus, inhalation anesthetics used, MAC.h of anesthesia, the duration of operation, blood loss, amount of blood transfusion, urine volume during operation, and surgical site. Serum GOT, GPT, total bilirubin, BUN and serum creatinine were examined on the 3rd and 7th day after surgery. An increase in serum GOT, GPT or bilirubin was observed for each of the following parameters; male, infection with hepatitis C virus, long operation, and upper abdominal surgery. Postoperative BUN and serum creatinine increased in patients with preoperative renal dysfunction, in elderly patients, and in hepatitis C carriers.

[Classification of post-cordotomy dysesthesia].

Postcordotomy dysesthesia was classified from the clinical features of dysesthesia following percutaneous cervical cordotomy (PCC) in 66 patients. Dysesthesia occurred in 10 (15.2%) of 66 patients and was classified into three types. In the first type, dysesthesia occurred at the region where pain had been before PCC, and pain sensitivity had been lost due to PCC. This type of dysesthesia occurred in 6 patients. In this type, the peripheral nerve damage caused by tumor invasion was presumably the cause of dysesthesia. In the second type, dysesthesia occurred all over the region where pain sensitivity had been lost due to PCC. This type of dysesthesia occurred in 2 patients. The destruction of second order neurons of the nociceptive pathway by PCC was presumably the cause of this type of dysesthesia. In the third type, dysesthesia occurred at the region where pain had been before PCC and pain sensitivity had partially recovered. This type of dysesthesia occurred in 3 patients. The reduction of the effect of PCC was presumably the cause of this type of dysesthesia.

[Evaluation of efficiency of ACD-CPR and STD-CPR; a multi-institutional study].

We compared the efficacy of ACD-CPR and STD-CPR based on 64 multi-institutional reports. No significant differences were observed in the rate of restoration of spontaneous circulation (ROSC) and in cardiopulmonary parameters during CPR using the two methods. There were 5 cases in which cardiopulmonary parameters improved after switching from STD-CPR to ACD-CPR and, eventually, in two of them spontaneous circulation was restored. In the ROSC cases of both groups, ETCO2 and values of SpO2, PaO2, and systolic BP at 30 minutes were higher than those of non-ROSC cases. ETCO2 never exceeded 20 mmHg in the non-ROSC cases, but it was higher in the ROSC cases. ACD-CPR is a good choice when trained persons are present or when extra hands are available to continue the CPR.

[An experience with Nakajo's method for large intact omphaloceles --success in 6 newborn infants].

Six serial newborn cases with large intact omphaloceles treated by Nakajo's method (modified Schuster's) were reported. The different point of this method from Schuster's is as follows; the silastic sheets are sutured to the skin around omphalocele, not to the rectus fascia. This procedure can be carried out under local anesthesia. As amnionic membrane leaves intact, reduction and trimming of the sheet can be safely done without anesthesia and injury of the intestine can be avoided. Stretching the abdominal wall and increasing the size of the abdominal cavity are the same as in Schuster's method. In this series, direct suture of abdominal wall became possible within a 5 to 10 day period after the first procedure. All six babies are alive. In conclusion, Nakajo's method is safe and useful one for large intact omphaloceles.

[An analysis of pain associated with cancer of various origins].

The authors retrospectively investigated the incidence and duration of pain associated with cancer of various origin by means of a multivariate analysis in 444 patients who have died of cancer. The author also examined the correlation of severity of pain with the number of days from last admission to the hospital to the day of death. Results have indicated that the incidence of severe pain of long duration is high in relatively younger patients, those who are 55-years-old or under, and also in patients with rectal, uterine or ovarian cancer. Patients with a severer pain tended to be admitted to the hospital in a much earlier stage of the disease. In patients with risk of severe pain, an advanced plan to control cancer pain is helpful, as are analgesic approaches which can help the patient to remain at home as long as possible is desirable.

The influence of obesity and underweightness on respiratory function of geriatric patients undergoing surgery.

We investigated the influence of obesity and underweightness on the respiratory function of 228 patients over 65 ys. old undergoing elective surgery. The parameters we studied were preoperative Pa(O)(2) (Pa(O)(2)-pre), Pa(O)(2) under general anesthesia (Pa(O)(2)-op) and preoperative spirometric values including data from flow-volume curves and closing volumes. Triceps skinfold thickness (TSF), body mass index (BMI), Broca's index (BI) and Onodera's prognostic nutritional index (PNI) were measured or calculated. Respiratory parameters were compared between 3 groups; overweight (BMI >23), normal weight (BMI 20-22), underweight (BMI <19). Single and multiple correlations were analyzed between 3 nutritional parameters (BMI, TSF, PNI) and respiratory values. As a result, Pa(O)(2)-pre and Pa(O)(2)-op in overweight group were lower than those in the other groups. None of other parameters showed significant differences between the 3 groups. In multiple regression analysis, BMI correlated with Pa(O)(2)-pre (r = -0.24), Pa(O)(2)-op (r = -0.43), %VC (r = 0.18), peak flow rate (PFR, r = 0.17) and V(50)/HT (r = 0.18). TSF correlated with Pa(O)(2)-pre (r = -0.22), %MVV (r = -0.28) and RV/TLC (r = 0.28). PNI correlated with PFR (r = 0.23). We concluded that overweightness has greater influence on respiratory function of elderly patients than underweightness and that arterial blood gas analysis is essential in preoperative assessment of obese geriatric patients.

Optimum dose of epidural morphine for postsurgical analgesia.

To determine the optimum dose of epidural morphine for postoperative pain control, 0.5-4.0 mg of morphine was administered to 198 patients who had undergone operations on lower abdomen or lower extremities under continuous epidural anesthesia. Analgesic effect of morphine and incidence of nausea or vomiting were studied using linear discriminant analysis. As explanatory variables, age and dose of morphine were statistically significant in discriminating analgesic effect of morphine. Among indices for physique of patients, height was the most useful for predicting the analgesic effect. The dose which made the discriminant function zero corresponded to the minimum effective dose (MED) of morphine and it was expressed as follows; MED (mg.meter(-1)) = -0.0107 x age + 1.85. Predicting the incidence of nausea or vomiting in relation to the dose of morphine did not reach a level of statistical significance.

The patency of the airway via each upper airway orifice during general anesthesia.

The patency of the airway via each orifice was examined during general anesthesia in 112 patients by occluding other orifices in order to develop a method in which fiberoptic endotracheal intubation (FEI) and ventilation could be performed via different orifices. Ventilation was well maintained via the mouth in 61 (54.5%), via bilateral nostrils in 87 (77.7%), and via the unilateral right and left nostril in 67 (59.8%) and 73 (65.2%) patients, respectively. With the aid of an artificial airway, ventilation was well maintained via the mouth in 112 (100.0%), via bilateral nostrils in 111 (99.1%), and via the unilateral right and left nostril in 106 (94.6%) and 105 (93.8%) patients, respectively. Based on these findings, we developed a method in which FEI is performed via the nostril, while ventilation is performed with a mask applied over only the mouth.

Neuroleptic malignant-like syndrome: a complication of acute organophosphate poisoning.

We report a 60-yr-old woman with schizophrenia, who manifested a neuroleptic malignant (NM)-like syndrome after acute organophosphate poisoning (OPP). She attempted suicide by ingesting 40% emulsions of DMTP (S-2,3-dihydro-5-methoxy-2-oxo-1,3,4-thiadizol-3-yl-methyl O,O-dimethyl phosphorodithioate) 100 ml. On admission, she was unconscious and demonstrated convulsions, depressed respiratory movements, miosis and profuse salivation. Plasma cholinesterase concentration (842 IU.L-1) was very low and OPP was diagnosed. She was treated with gastric lavage, atropine and pralidoxime (PAM). By the seventh day after admission, symptoms of OPP disappeared and serum ChE had recovered to a sub-normal level. On the 13th day, she demonstrated coma, high fever (41.0 degrees C) and lead-pipe rigidity. Serum CPK was increased (1631 IU.L-1). Dantrolene sodium iv was administered for three days. Body temperature began to decrease in 24 hr, and her consciousness, muscle rigidity and other neurological symptoms returned to normal by the 16th day after admission. She was discharged from the hospital without sequelae 55 days after admission. We conclude that OPP can predispose to an NM-like syndrome and that dantrolene may be effective in the management.