The Japanese Epidemiologic Study for Perioperative Anaphylaxis, a prospective nationwide study: allergen exposure, epidemiology, and diagnosis of anaphylaxis during general anaesthesia.

BACKGROUND: Diagnosis of perioperative anaphylaxis is often challenging. This study describes the utility of a newly developed tool for identifying patients with a high possibility of anaphylaxis, and aimed to investigate the frequency of anaphylaxis with each drug during the perioperative period in Japan. METHODS: This study included patients with anaphylaxis of Grade 2 or higher severity during general anaesthesia at 42 facilities across Japan in 2019 and 2020. We developed and adopted a unique objective evaluation tool yielding a composite score for diagnosing anaphylaxis, which includes the results of skin tests and basophil activation tests, and clinical scores for perioperative anaphylaxis. The number of cases using each drug and the total number of anaphylaxis cases were investigated to calculate the frequency of anaphylaxis. RESULTS: General anaesthesia was performed in 218 936 cases, which included 55 patients with suspected perioperative anaphylaxis. The developed composite score diagnosed 43 of them with a high probability of anaphylaxis. The causative agent was identified in 32 cases. Plasma histamine levels showed high diagnostic accuracy for anaphylaxis. The top causative agents were rocuronium (10 cases in 210 852 patients, 0.005%), sugammadex (7 cases in 150 629 patients, 0.005%), and cefazolin (7 cases in 106 005 patients, 0.007%). CONCLUSIONS: We developed a composite tool to diagnose anaphylaxis, and found that the combination of tryptase levels, skin testing, and basophil activation testing results and clinical score improved the certainty of anaphylaxis diagnosis. The incidence of perioperative anaphylaxis in our study was 1 in about 5000 general anaesthesia cases. CLINICAL TRIAL REGISTRATION: UMIN000035350.

[Persistent Disturbance of Consciousness after Clipping of an Unruptured Cerebral Aneurysm due to Pseudohypoxic Brain Swelling].

A patient developed persistent disturbance of consciousness after uneventful clipping of an unruptured cerebral aneurysm under general anesthesia. Pseudohypoxic brain swelling (PHBS) was suspected because computerized tomography (CT) and magnetic resonance imaging (MRI) revealed diffuse brain swelling, especially in the bilateral basal ganglia and thalami. Steroid pulse therapy in addition to antiedematous drugs and anticonvulsant improved the consciousness. Anesthesiologists should pay attention to PHBS in a case of persistent disturbance of consciousness after uneventful craniotomy.

Attitudes toward automated external defibrillator use in Japan in 2011.

PURPOSE: Early use of an automated external defibrillator (AED) improves the chances of successful resuscitation and survival. We have surveyed Japanese individuals on their attitude towards using an AED if they witnessed a cardiac arrest and compared the results with those of our previous study in 2006. METHODS: Participants were asked to complete questionnaires regarding their familiarity with the AED concept and their willingness to use AEDs. RESULTS: A total of 2,527 high school students, teachers, medical nurses, and medical students completed the questionnaire; the characteristics of these individuals were not statistically different from those of the participants of our previous study. In total, 47 % of the high school students, 89 % of the teachers, 93 % of the nurses, and all of the medical students responded that they were familiar with the concept and use of AEDs. The percentages of high school students, teachers, and nurses indicating a familiarity with AEDs were significantly higher in the current study than in the 2006 study. In total, 73 % of the high school students, 87 % of the teachers, 98 % of the nurses, and all of the medical students surveyed in the current study claimed they would definitely use AEDs if required; these values were also significantly higher than those obtained in 2006. CONCLUSIONS: The number of Japanese individuals who are familiar with the concept of AEDs and who are also willing to use these devices was considerably higher in the current study than in the 2006 study. However, more Japanese individuals should be made aware of AEDs and become familiar with their use.

[One-lung ventilation with a handmade double-lumen tube in an infant for video-assisted thoracoscopic surgery].

A 3-month-old infant was scheduled for video-assisted thoracoscopic surgery for sequestration of the right lung. One-lung ventilation was performed with our handmade double-lumen tube. Intubation was performed easily using a laryngeal fiberscope and X-ray fluoroscopy. Good thoracoscopic view was obtained with simple deflation of the right lung. Perioperative course was uneventful.

[Risk management in brachial plexus block].

Peripheral nerve block has many advantages in surgical anesthesia with or without general anesthesia; postoperative analgesia, faster postoperative rehabilitation, and chronic pain management. However, serious adverse complications after peripheral nerve block can happen. Therefore, anesthetists should obtain full informed consent for possible complications, and require scrupulous attention to this procedure. This review focuses on complications of brachial plexus block because it is the most popular peripheral nerve block.

The effects of carvedilol administration on cardiopulmonary resuscitation in a rat model of cardiac arrest induced by airway obstruction.

BACKGROUND: Carvedilol is a nonselective ß-adrenoceptor and selective α(1)-adrenoceptor blocker and is widely used in the treatment of patients with hypertensive and/or chronic heart failure because, unlike classic ß-blockers, this drug has additional endothelium-dependent vasodilatory effects. We evaluated the effects of oral administration of carvedilol on cardiopulmonary resuscitation (CPR) in a rat model of cardiac arrest (CA) induced by airway obstruction. METHODS: Twenty-four rats were randomly assigned to 2 groups: control group (no medication) and treatment group (oral administration of carvedilol [10 mg/kg/d] for 5 days) (n = 12 per group). All the animals were anesthetized, and CA was induced by obstructing the airway. Three minutes after CA, the animals were revived by administering CPR. The rate of chest compressions (CCs) was 240 to 260 CCs/min and the depth of CCs was adjusted to maintain the diastolic arterial blood pressure between 25 to 30 mm Hg in both groups. Epinephrine (0.02 mg/kg) was administered after 5 minutes of CPR. No other therapy was administered before, during, or after CA. RESULTS: The time interval between airway obstruction and CA in the treatment group was significantly longer than in the control group (230 ± 27 vs 203 ± 24 seconds; P < 0.05). The rate of return of spontaneous circulation in the treatment group was significantly higher than in the control group (92% vs 50%; P < 0.05). Acidosis and increased glucose and tumor necrosis factor-α concentrations in the treatment group were significantly lower than in the control group. CONCLUSIONS: The results of our study showed that rats that had been administered oral carvedilol for several days were more resistant to CA induced by airway obstruction, and when CA did occur, were more likely to be resuscitated. These findings suggest that carvedilol may prolong the safe ischemic time induced by respiratory failure.

Effects of direct hemoperfusion using a cytokine-adsorbing column on endotoxin-induced experimental acute lung injury in rats.

BACKGROUND: Effects of direct hemoperfusion with a cytokine-adsorbing column, CTR, on endotoxin-induced experimental acute lung injury in rats were evaluated. METHODS: 36 Sprague-Dawley rats were ventilated mechanically and allocated to one of the following three groups (n = 12 per group): saline control, saline instilled into trachea; endotoxin control, endotoxin (40 mg/kg) instilled into trachea, and treatment group, CTR treated for 90 min after endotoxin (40 mg/kg) instillation. Blood gases, cytokine concentrations and lung histopathology were evaluated. RESULTS: The decreased PaO(2) in the treatment group had recovered at 120 min after instillation and was significantly higher than that in the endotoxin control. The increased PaCO(2) in the endotoxin control was significantly higher than that in the treatment group. The elevated cytokine concentrations and the neutrophil infiltration into the lungs were less in the treatment group than in the endotoxin control. CONCLUSION: The present study showed that CTR treatment inhibited hypoxia, hypercapnia, and inflammatory responses in an acute lung injury model.

[Anesthetic management of a patient with acquired factor V inhibitor].

A 74-year-old man was scheduled for laparoscopic low anterior resection of rectal cancer. Preoperative blood coagulation test showed his prothrombin time (PT) and activated partial thromboplastin time (APTT) remarkably prolonged. However, he experienced only slight epistaxis. Further examination suggested the presence of acquired factor V inhibitor. Plasmapheresis was carried out before surgery to eradicate inhibitors, but improvement of PT and APTT was temporary. We prepared platelet transfusion and recombinant activated factor VII (rFVIIa) for acute intraoperative bleeding, but there were no abnormal episodes during the surgery. On postoperative day 15, the patient suddenly passed blood in his stool, and received platelet transfusion. For the majority of patients with acquired factor V inhibitor, bleeding is usually mild, but fatal bleeding complications have also been reported. Platelet transfusion was effective in the patient described here.

Comparison of a cytokine adsorbing column and an endotoxin absorbing column for the treatment of experimental endotoxemia.

The present study compared the effects of direct hemoperfusion (DHP) using a cytokine absorbing (CTR) column with those using an endotoxin absorbing (PMX) column with endotoxin-induced shock in rats. Thirty-six rats were injected intravenously with endotoxin (15 mg/kg), and then allocated into one of the following three groups: control group, treated without CTR; PMX group, treated with a PMX column for 120 min; CTR group, treated with a CTR column for 120 min. The present study showed that CTR treatment decreased the mortality rate 8h after endotoxin injection and inhibited inflammatory responses (cytokine, hemodynamics and acidosis) similar to PMX treatment.

Dose-related effects of direct hemoperfusion using a cytokine adsorbent column for the treatment of experimental endotoxemia.

OBJECTIVE: To clarify the dose-related effects of direct hemoperfusion using a cytokine adsorbent column (CTR) on the mortality and inflammatory responses to endotoxin-induced shock in rats. DESIGN: Prospective and randomized study. SETTING: University research laboratory. SUBJECTS: Male Wistar rats. INTERVENTIONS: Forty-eight rats were injected intravenously with Escherichia coli endotoxin (15 mg/kg over 2 min), and then were randomly allocated to one of the following four groups (n = 12 per group): control group, treated without CTR for 120 min; quarter-dose treatment group, treated with CTR 0.25 ml for 120 min; half-dose treatment group, treated with CTR 0.50 ml; and full-dose treatment group, treated with CTR 1.0 ml. MEASUREMENTS AND RESULTS: Hemodynamics and arterial blood gases were recorded, and mortality and plasma cytokine concentrations were calculated for the 8-h observation period. The mortality rates 8 h after endotoxin injection were 92%, 58%, 42% and 17% for the control column, quarter-dose, half-dose, and full-dose CTR groups, respectively. The increases in plasma cytokine concentrations were smaller in the half-dose and full-dose CTR treatment groups than in the endotoxemic group. CONCLUSIONS: The present study showed that CTR treatment dose-dependently decreased the mortality rate and inhibited inflammatory responses in vivo.

Effects of carvedilol on mortality and inflammatory responses to severe hemorrhagic shock in rats.

The nonselective beta-adrenoceptor and the selective alpha1-adrenoceptor blocker carvedilol are widely used in hypertensive and/or cardiac failure patients because of its efficacy. However, there have been few studies regarding the effects of carvedilol on severe hemorrhagic shock. The present study was performed to evaluate the effects of carvedilol on severe hemorrhagic shock in rats. Twenty-four male Sprague-Dawley rats were randomly assigned to 1 of the following 2 groups (n = 12 per group): control group, no medication; and treatment group, oral administration of carvedilol (10 mg/kg per day) for 5 days. All animals were anesthetized with i.p. pentobarbital. Severe hemorrhagic shock was induced by partial exsanguination. Eight minutes after shock, all removed blood was returned to the animal. No other treatments were administered before, during, or after shock. Hemodynamics and arterial blood gases were recorded, mortality was calculated for the 5-h observation period, and plasma cytokine concentrations were measured at 5 h after shock. The mortality rates at 5 h after cardiac arrest were 8% and 50% for control and treatment groups, respectively. The increases in base deficit and lactate concentrations were less in the control group than that in the treatment group. Moreover, the increases in TNF-alpha concentrations were less in the control group than in the treatment group. The present study indicated that oral administration of carvedilol had adverse effects on mortality and inflammatory responses to severe hemorrhagic shock in rats. These findings suggest that carvedilol may adversely affect recovery from severe hemorrhagic shock.

Dose- and time-related effects of dexmedetomidine on mortality and inflammatory responses to endotoxin-induced shock in rats.

PURPOSE: Our previous study demonstrated that dexmedetomidine drastically reduced mortality and inhibited the inflammatory response during endotoxemia in rats. The aim of this study was to clarify the dose- and time-related effects of dexmedetomidine on mortality and inflammatory responses to endotoxemia in rats. METHODS: Male Wistar rats (n = 96) were anesthetized intraperitoneally with pentobarbital sodium and assigned to one of two protocols: one representing the dose-related effects of dexmedetomidine, and the other, the time-related effects of dexmedetomidine. To evaluate the dose-related effects, the animals were randomly assigned to one of four groups (n = 15 each): endotoxemic group (group E), receiving intravenous Escherichia coli endotoxin (15 mg x kg(-1) over 2 min); small-dose group (group S), treated with a small dose of dexmedetomidine (2.5 microg x kg(-1) x h(-1), IV); medium-dose group (group M), treated with a medium dose (5 microg x kg(-1) x h(-1), IV); and large-dose group (group L), treated with a large dose (10 microg x kg(-1) x h(-1), IV). To evaluate the time-related effects, the animals were randomly assigned to one of three groups (n = 12 per group): endotoxemic group; early posttreatment group, treated with 10 microg x kg(-1) x h(-1) dexmedetomidine at 1 h after endotoxin injection; and late posttreatment group, treated with 10 microg x kg(-1) x h(-1) at 2 h after endotoxin injection. Hemodynamics and arterial blood gases were recorded and plasma cytokine concentrations were measured throughout the observation period. The mortality rate was assessed up to 8 h after endotoxin injection. RESULTS: In the dose-related study, the mortality rates at 8 h after endotoxin injection were 81%, 26%, 32%, and 20% for groups E, S, M, and L, respectively. Plasma tumor necrosis factor-alpha (TNF) concentrations were lower in groups M and L than in group E at 2 h after endotoxin injection. Plasma interleukin-6 (IL-6) concentrations were lower in groups M and L than in group E at 4 and 5 h after endotoxin injection. In the time-related study, the mortality rates at 8 h after the endotoxin injection were 83%, 33%, and 58% for the endotoxemic, early posttreatment, and late posttreatment groups, respectively. The TNF concentration was lower in the early posttreatment group than in the endotoxemic group at 2 h after endotoxin injection, and the IL-6 concentration was lower in the early posttreatment group than in the endotoxemic group at 5 h after endotoxin injection. CONCLUSION: Dexmedetomidine dose-dependently attenuated extremely high mortality rates and increases in plasma cytokine concentrations after endotoxin injection. Moreover, the early administration of dexmedetomidine drastically reduced the high mortality rate and inhibited cytokine responses in endotoxin-exposed rats. These findings suggest that dexmedetomidine administration may be effective during sepsis.