Expression and release of the a and b subunits for human coagulation factor XIII in baby hamster kidney (BHK) cells.

The a subunit of coagulation factor XIII lacks a hydrophobic signal sequence for secretion from cells, while the b subunit has a typical signal sequence. To determine whether the a subunit can be synthesized and released, expression vectors containing the cDNA for either subunit were transfected into baby hamster kidney (BHK) cells. Western blotting analysis and gel filtration chromatography demonstrated that the recombinant a and b subunits (rXIIIa and rXIIIb) had the same molecular weights and subunit structures (a2, b2, and a2b2) as the native molecules. rXIIIa was enzymatically active when activated by thrombin. Most rXIIIb was secreted as measured by ELISA, while most rXIIIa was detected in the cytosol by subcellular fractionation. Co-expression with rXIIIb in the same cells did not promote the release of rXIIIa. Treatment of the cells with brefeldin A, a potent inhibitor of protein transportation, blocked the secretion of rXIIIb, although it had no effect on the release of rXIIIa. Several drugs and heat stress induced the release of rXIIIa, which correlated directly with that of cytoplasmic lactate dehydrogenase. These results suggest that the a subunit is released from cells as a consequence of cell injury, which is independent of the classical secretory pathway.

A characteristic property of vitamin K-dependent plasma protein Z.

Evidence is presented for rapid, limited proteolysis of protein Z by alpha-thrombin. This alpha-thrombin-catalyzed proteolysis of protein Z occurred at a single peptide linkage, between Arg-365 and Gly-366, located in the COOH-terminal portion. The resulting NH2-terminal large fragment (PZt) and the COOH-terminal peptide (C-peptide) were isolated and chemically characterized. The C-peptide consisted of 31 amino acid residues including one galactosamine-type Thr residue and was assigned to the position from Gly-366 to the COOH-terminal residue of Val-396 in protein Z. The NH2-terminal large fragment, PZt, constituted the remainder of protein Z. The abilities to bind calcium of intact protein Z, PZt, and the derivative of protein Z devoid of the NH2-terminal gamma-carboxyglutamic acid (Gla) domain (Gla-domainless), prepared with the known chymotrypsin treatment, were examined by equilibrium dialysis. The results indicated that intact protein Z and PZt contain four calcium binding sites with dissociation constants of 0.1 mM. Moreover, the Scatchard plot analysis showed positive cooperativity, suggesting the presence of at least two initial sites for calcium binding. In contrast, the Gla-domainless protein Z had no calcium binding site, indicating that the domain of protein Z functional for calcium binding occurs within the NH2-terminal Gla domain. This differed from factor X, factor IX, protein S, and protein C, all of which contain one or two calcium binding site(s) independent on their Gla-domains.

Large-scale preparation of human thrombin: polyethylene glycol potentiates the factor Xa-mediated activation of prothrombin.

We investigated the ability of polyethylene glycol 4000 to accelerate thrombin generation in a mixture of prothrombin and factor X at concentrations of 1-30%. In the presence of 5 mM of CaCl2, polyethylene glycol 4000 promoted prothrombin activation at concentrations above 1%. The peak of activation was seen at levels of 14 and 20% of polyethylene glycol 4000. The effect of the polyethylene glycol was remarkably dependent on its molecular weight; molecular weights greater than 2000 were required for accelerating thrombin generation. Under optimal conditions, polyethylene glycol 4000, in the presence of CaCl2, promoted conversion of all of the prothrombin into thrombin and its derivatives. We conclude that polyethylene glycol 4000, at concentrations ranging from 14 to 20%, effectively accelerates thrombin generation in the presence of 5 mM of CaCl2. This new method for preparing thrombin is based on the use of polyethylene glycol 4000 and CaCl2 and is applicable to the manufacture of thrombin.

Relief of post-tonsillectomy pain by release of lidocaine from fibrin glue.

OBJECTIVES: Pain inevitably develops after resection of the palatine tonsil (tonsillectomy). Therefore, we applied a mixture of lidocaine and fibrin glue to the tonsillar fossae immediately after tonsillectomy and evaluated its analgesic effects. STUDY DESIGN: A prospective randomized trial. METHODS: Seventy-four consecutive patients who had undergone tonsillectomy by the same surgeon (S.K.) were allocated by the sealed envelope method into three groups. After routine tonsillectomy, the operation was terminated in group A (control group), but the bilateral tonsillar fossae were covered with 1 mL fibrin glue using CaCl2 as solution to dissolve thrombin in group B and using 4% lidocaine chloride instead of CaCl2 in group C. No significant difference was observed in age or sex among the three groups. Analgesic effects were evaluated in terms of the postoperative days required until the patient began to eat normally and the postoperative days on which the patient desired analgesic administration. RESULTS: The mean postoperative days until the patient began to eat normally were 4.22 in group A and 3.78 in group B, showing no significant difference, but 2.83 in group C, being significantly shorter (P <.05). The mean postoperative days on which analgesic administration was necessary were 4.56 in group A and 4.91 in group B, showing no significant difference, but 2.88 in group C, being significantly shorter (P <.05). CONCLUSION: This method can be readily performed, requires no special treatment, and appears to have adequate pain-relieving effects.

Effects of nilvadipine on the cardiovascular responses to tracheal intubation.

STUDY OBJECTIVE: To evaluate the efficacy of nilvadipine given orally in attenuating the hypertensive response to laryngoscopy and intubation. DESIGN: Controlled, randomized, double-blind study. SETTING: Induction of anesthesia for elective surgery at a university hospital. PATIENTS: Thirty normotensive patients (ASA physical status I) undergoing elective surgery were divided into three groups of ten patients each. INTERVENTIONS: Either 2 mg of nilvadipine, 4 mg of nilvadipine, or a placebo (control) was administered orally 90 minutes before induction of anesthesia. Anesthesia was induced with thiopental sodium 5 mg/kg intravenously, and tracheal intubation was facilitated with vecuronium 0.2 mg/kg. During anesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide (N2O) in oxygen. Laryngoscopy lasting 30 seconds was attempted 2 minutes after administration of thiopental sodium and vecuronium. MEASUREMENTS AND MAIN RESULTS: Patients receiving the placebo showed a significant increase in mean arterial pressure (MAP) and heart rate associated with tracheal intubation. The increase in MAP following tracheal intubation was significantly lower in nilvadipine-treated patients than in the control group (p less than 0.05). However, neither dose of nilvadipine attenuated the tachycardic response to intubation. CONCLUSIONS: Oral administration of nilvadipine before induction of anesthesia is a simple and practical method for attenuating pressor response to laryngoscopy and tracheal intubation after standard elective induction under additional 1% enflurane-N2O anesthesia.

Attenuation of hypertensive response to tracheal intubation with nitroglycerin.

STUDY OBJECTIVE: To evaluate the efficacy and safety of intravenous (IV) nitroglycerin in attenuating the hypertensive response to laryngoscopy and intubation as a new application of the drug. DESIGN: Controlled, randomized, double-blind study. SETTING: University hospital. PATIENTS: Thirty normotensive patients (ASA physical status I) undergoing elective surgery were divided into three groups of ten patients each. INTERVENTIONS: Anesthesia was induced with thiopental sodium 5 mg/kg i.v., and tracheal intubation was facilitated with vecuronium 0.2 mg/kg i.v. During anesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Either 1.5 micrograms/kg of nitroglycerin, 2.5 micrograms/kg of nitroglycerin, or saline (control) was administered IV simultaneously with the start of laryngoscopy (lasting 30 seconds), which was attempted 2 minutes after administration of thiopental sodium and vecuronium. MEASUREMENTS AND MAIN RESULTS: Patients receiving saline showed a significant increase in mean arterial pressure and rate-pressure product associated with tracheal intubation. These increases following tracheal intubation were significantly reduced in nitroglycerin-treated patients compared with those in the control group (p < 0.05). CONCLUSION: A single, rapid IV dose of nitroglycerin is a simple, practical, effective, and safe method to attenuate the hypertensive response to laryngoscopy and tracheal intubation.

Partial attenuation of the cardiovascular responses to tracheal intubation with oral nisoldipine.

STUDY OBJECTIVE: To evaluate the efficacy and safety of nisoldipine given orally in attenuating the cardiovascular responses to laryngoscopy and tracheal intubation. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Induction of anesthesia for elective surgery at a university hospital. PATIENTS: Thirty normotensive patients (ASA physical status I) undergoing elective surgery were assigned to one of three groups; placebo, nisoldipine 5 mg, or nisoldipine 10 mg. Each group consisted of ten patients. INTERVENTIONS: Either 5 mg of nisoldipine, 10 mg of nisoldipine, or a placebo was administered orally 2 hours before induction of anesthesia. Anesthesia was induced with thiopental sodium 5 mg/kg intravenously, and tracheal intubation was facilitated with vecuronium 0.2 mg/kg. During anesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Laryngoscopy lasting 30 seconds was attempted 2 minutes after administration of thiopental sodium and vecuronium. MEASUREMENTS AND MAIN RESULTS: Patients receiving the placebo showed a significant increase in mean arterial pressure associated with tracheal intubation. These increases following tracheal intubation were significantly reduced in patients receiving nisoldipine 10 mg compared with patients receiving the placebo (p less than 0.05). CONCLUSIONS: Oral administration of nisoldipine before induction of anesthesia is a simple, practical, and safe method for attenuating pressor response to laryngoscopy and tracheal intubation.

[Comparison of continuous epidural fentanyl and morphine for postoperative pain management after upper abdominal surgery].

Fentanyl and morphine were administered epidurally to the patients after upper abdominal surgery for postoperative pain management. One hundred and ninety patients were divided into 3 groups; F group: bolus and continuous administration of fentanyl, M group: bolus and continuous administration of morphine, FM group: bolus of fentanyl and morphine and continuous administration of morphine. Pain scores of 1, 2, 3, 4, 8, 12 hours after administration and of the next morning were examined and side effects were recorded. Pain scores at 1 and 2 hours in F and FM group were significantly lower than those in M group. There were no significant differences in the scores among 3 groups from 3 hours to the next morning. The incidence of itching in F group was significantly less than in other groups. Respiratory depression (less than respiratory rate 8.min-1) occurred in 2 cases in M and FM group, but no case in F group. FM group had no advantage compared with F group. We conclude that continuous epidural infusion of fentanyl is more useful than morphine for postoperative pain management after upper abdominal surgery.

[Post dural puncture headache (PDPH) which occurred after the removal of an epidural catheter].

A 57-year-old man received gastrectomy under general anesthesia combined with epidural anesthesia. He showed no signs of dural puncture and catheter migration into the subarachnoid space. Cardiovascular status was stable with epidural injection of lidocaine, morphine during the operation. Although epidural morphine and buprenorphine infusions were continued for 1 to 6 postoperative days, respiratory depression and other side effects were not observed. However, severe headache in the upright position occurred after stopping these infusions and the removal of the catheter on the 7th postoperative day. The headache was thought to be caused by unintentional dural puncture. PDPH persisted over a period of 30 days and was treated with an epidural blood patch and stellate ganglion blocks since the other conservative therapy had been ineffective. We consider that administration of continuous epidural opioids for postoperative analgesia helped to prevent PDPH until the 7th postoperative day. We also conclude that prolonged PDPH after using a thick needle like a Touhy needle should be treated by an epidural blood patch.

[Postoperative nausea and vomiting after gynecologic abdominal surgery--a comparison of propofol versus inhalational technique].

Propofol has been reported to reduce emesis. This study was performed to evaluate the incidence of postoperative nausea and vomiting (PONV) in gynecologic abdominal surgery patients after propofol anesthesia and inhalational anesthesia. Sixty patients were evaluated for the incidence of PONV. Thirty patients received oxygen-propofol-epidural anesthesia (propofol group) and the others were maintained with nitrous oxide-oxygen-isoflurane/sevoflurane--epidural anesthesia (inhalational group). The incidence of PONV was 33.3% in propofol group and 60% in inhalational group (P < 0.05). The means of frequency of postoperative nausea were 0.63 and 1.97 in propofol-group and inhalational group, respectively (P < 0.05). Those of postoperative vomiting were 0.17 after propofol and 1.00 following inhalational anesthesia (P < 0.01). For the gynecologic abdominal surgery patients, PONV was significantly less following intravenous anesthesia with propofol than after isoflurane or sevoflurane inhalational anesthesia. This study indicated that propofol anesthesia was useful in reducing PONV after gynecologic abdominal surgery.

[Analgesic effects of epidurally administered fentanyl for postoperative pain relief--comparison with buprenorphine].

We did a retrospective study on 177 patients after upper and lower abdominal surgery, and compared the efficacy of epidural administration of fentanyl and that of buprenorphine for postoperative pain relief. In fentanyl (F) group, 73 patients received fentanyl 0.1 mg with saline 8 ml epidurally after operation, followed by a constant rate infusion of 0.025 mg.hr-1 for 18-24 hrs. In buprenorphine (B) group, 104 patients, received buprenorphine 0.2 mg with saline 9 ml epidurally. After upper abdominal surgery, 33 patients (76.7%) in F group and 27 patients (52.9%) in B group obtained satisfactory analgesia (P < 0.05). The difference of the degree of analgesia after lower abdominal surgery was not significantly different in both groups. Respiratory depression occurred in 19 patients in B group and 5 patients in F group (P < 0.05). It is concluded that epidural fentanyl delivered by continuous infusion offers a significant advantage compared with epidural buprenorphine for postoperative pain relief following upper abdominal surgery.

[Anesthesia in a patient with epidermolysis bullosa].

Epidermolysis bullosa hereditaria, a rare inherited disorder presents clinically with recurrent cutaneous blister formation with possible involvement of mucous membrane and organs following minimal trauma. The sequelae of this disease pose significant anesthetic problems to operating room staffs. We describe the anesthetic management of a 32-year old woman with epidermolysis bullosa hereditaria who underwent palmar skin graft using regional anesthesia, and discuss the problems associated with this disease.

Continuous infusion of vecuronium in children.

The average dose of vecuronium required in children continuous infusion to attain a steady state block of 90% was determined. The electromyographic (EMG) response and mechanical response to supramaximal stimulation of the ulnar never recorded simultaneously, were significantly correlated in four children. The steady-state infusion rate requirement of vecuronium was 1.4 +/- 0.03 micro g/kg/min during 2% enflurane anesthesia and 3.1 +/- 0.03 micro g/kg/min during 1% halothane anesthesia. The spontaneous recovery time to 25% of the control by EMG during halothane and enflurane anesthesia was 12.6 +/- 1.1 and 10.3 +/- 1.5 min, respectively, after termination of the infusion. There was no cumulative effect after prolonged vecuronium infusion.

The effect of diltiazem on the cardiovascular response to tracheal intubation.

The efficacy of diltiazem in the attenuation of the cardiovascular response to laryngoscopy and tracheal intubation was studied in patients who received 0.2 or 0.3 mg/kg diltiazem 60 seconds before the start of laryngoscopy. These data were compared with a control group who received saline. Each group consisted of 10 patients who had elective surgery. Patients who received saline showed a significant increase in mean arterial pressure and rate pressure product associated with tracheal intubation. These increases after tracheal intubation were reduced in diltiazem-treated patients compared with those of the control group (p less than 0.05). The data suggest that a bolus injection of diltiazem is a simple, practical and effective method to attenuate the hypertensive response to laryngoscopy and tracheal intubation.

Effects of adenosine triphosphate on the cardiovascular response to tracheal intubation.

Laryngoscopy and tracheal intubation often cause hypertension and tachycardia, which may be exaggerated during rapid-sequence induction of anaesthesia. The efficacy of adenosine triphosphate (ATP) in attenuating this response was studied in patients receiving ATP 0.05 mg kg-1 or 0.1 mg kg-1 simultaneously with the start of laryngoscopy. These data were compared with those for a control group receiving saline. Each group consisted of 10 patients undergoing elective surgery. Anaesthesia was induced with thiopentone 5 mg kg-1 i.v. and tracheal intubation was facilitated with vecuronium 0.2 mg kg-1 i.v. During anaesthesia, ventilation was assisted or controlled with 1% enflurane and 50% nitrous oxide in oxygen. Patients receiving saline showed a significant increase in mean arterial pressure and rate-pressure product associated with tracheal intubation. These increase after tracheal intubation were reduced in ATP-treated patients compared with those of the control group (P less than 0.05). The data suggest that a bolus injection of ATP is a simple, practical and effective method for attenuating the hypertensive response to laryngoscopy and tracheal intubation.