The relationship between age and minimum alveolar concentration of sevoflurane for maintaining bispectral index below 50 in children.

We evaluated the minimum alveolar concentration of sevoflurane required to maintain the bispectral index below 50 in children. We studied 55 children, divided into 1-year-old, 2- to 4-year-old and 5- to 9-year-old groups and used Dixon's up-and-down method and probit analysis. In the 1-year-old group, the bispectral index values remained above 50, with the end-tidal sevoflurane concentration reaching 4.0% or higher. The minimum alveolar concentration of sevoflurane for maintaining the bispectral index below 50 was significantly higher in the 2- to 4-year-old group (2.33%, 95% CI 2.25-2.57) than in the 5- to 9-year-old group (2.10%, 95% CI 1.94-2.25; p = 0.005). We conclude that assessing the depth of anaesthesia using bispectral index is unreliable in children aged < 2 years anaesthetised with sevoflurane.

Progesterone decreases sevoflurane requirement in male mice: a dose-response study.

BACKGROUND: Progesterone has long been known to have central effects, by reduced anaesthetic requirements as measured by minimum alveolar concentration (MAC) in various settings. However, other studies have contradicted these findings. Therefore, we compared the effect of progesterone on anaesthetic requirements in a mouse model. METHODS: Male C57BL/6 mice were treated with either progesterone (37.5 or 75 mg kg(-1)) or the olive oil vehicle, 1 h before each experiment. Animals were placed in a revolving cylinder (4 rev min(-1)) and supplied with oxygen and stepwise increasing concentrations of sevoflurane. The number of complete rollovers during revolution of the chamber was counted as a measure of anaesthetic requirement. RESULTS: S.C. administration of progesterone 75 mg kg(-1) significantly reduced sevoflurane requirement (P<0.0001). Progesterone 37.5 mg kg(-1) did not change sevoflurane requirement. CONCLUSIONS: We conclude that administration of exogenous progesterone injection at higher concentrations decreases anaesthetic requirement as defined by rolling response.

Effects of fentanyl infusion on tracheal intubation and emergence agitation in preschool children anaesthetized with sevoflurane.

BACKGROUND: Sevoflurane can be used as a sole agent for intubation in children, but studies have suggested that it is associated with emergence agitation. Fentanyl infusions can be used both to facilitate intubation and decrease emergence agitation. We investigated the effects of fentanyl on conditions at intubation and on emergence from sevoflurane anaesthesia without confounding nitrous oxide or premedication. METHODS: IRB approval and informed consent were obtained. Subjects comprised 150 ASA physical status I or II (age, 2-6 yr). Anaesthesia was induced with sevoflurane in oxygen and maintained using a predetermined concentration of sevoflurane. Subjects were randomly allocated to receive one of three doses of fentanyl: vehicle only (control group), a bolus dose of 1 microg kg(-1) followed by a continuous infusion of 0.5 microg kg(-1) h(-1) (F1 group), or a bolus dose of 2 microg kg(-1) followed by a continuous infusion of 1 microg kg(-1) h(-1) (F2 group). Sevoflurane minimum alveolar concentration for tracheal intubation (MAC(TI)) and emergence agitation score were assessed. RESULTS: MAC(TI) values were 2.49%, 1.61%, and 1.16% in control, F1, and F2 groups, respectively (P<0.05). Agitation scores were 11.5, 7.0, and 2.6 in control, F1, and F2 groups, respectively (P<0.05). CONCLUSIONS: Fentanyl infusion consisting of a bolus dose of 2 microg kg(-1) followed by a continuous infusion of 1 microg kg(-1) h(-1) facilitates tracheal intubation and smooth emergence in children anaesthetized using sevoflurane. CLINICAL TRIAL REGISTRATION: this study was started in 2000 and was finished in 2008. We had no registration number. IRB approval was obtained.

Long-term effect of modification of dietary protein intake on the progression of diabetic nephropathy: a randomised controlled trial.

AIMS/HYPOTHESIS: There is currently insufficient evidence to recommend a low-protein diet for type 2 diabetic patients with diabetic nephropathy. We assessed whether a low-protein diet could prevent the progression of diabetic nephropathy. METHODS: This was a multi-site parallel randomised controlled trial for prevention of diabetic nephropathy progression among 112 Japanese type 2 diabetic patients with overt nephropathy. It was conducted in Japan from 1 December 1997 to 30 April 2006. The participants were randomly assigned using a central computer-generated schedule to either low-protein diet (0.8 g kg(-1) day(-1)) and normal-protein diet (1.2 g kg(-1) day(-1)), and were followed for 5 years. The participants and investigators were not blinded to the assignment. The primary outcomes were the annual change in estimated GFR and creatinine clearance, the incidence of doubling of serum creatinine and the time to doubling of baseline serum creatinine. RESULTS: The study was completed by 47 (84%) of 56 participants in the low-protein diet group and 41 (73%) of 56 participants in the normal-diet group. During the study period, the difference in mean annual change in estimated GFR between the low-protein diet and the normal-protein diet groups was -0.3 ml min(-1) 1.73 m(-2) (95% CI -3.9, 4.4; p = 0.93). The difference in mean annual change in creatinine clearance between the low-protein diet and the normal-protein diet groups was -0.006 ml s(-1) 1.73 m(-2) (95% CI -0.089, 0.112; p = 0.80). A doubling of serum creatinine was reached in 16 patients of the low-protein group (34.0%), compared with 15 in the normal-protein group (36.6%), the difference between groups being -2.6% (95% CI -22.6, 17.5; p = 0.80). The time to doubling of serum creatinine was similar in both groups (p = 0.66). CONCLUSIONS/INTERPRETATION: It is extremely difficult to get patients to follow a long-term low-protein diet. Although in the low-protein group overall protein intake was slightly (but not significantly) lower, it did not confer renoprotection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00448526. FUNDING: Research grant from the Ministry of Health, Labour and Welfare of Japan.

Delayed development of nervous system in mice homozygous for disrupted microtubule-associated protein 1B (MAP1B) gene.

Microtubule-associated protein 1B (MAP1B), one of the microtubule-associated proteins (MAPs), is a major component of the neuronal cytoskeleton. It is expressed at high levels in immature neurons during growth of their axons, which indicates that it plays a crucial role in neuronal morphogenesis and neurite extension. To better define the role of MAP1B in vivo, we have used gene targeting to disrupt the murine MAP1B gene. Heterozygotes of our MAP1B disruption exhibit no overt abnormalities in their development and behavior, while homozygotes showed a slightly decreased brain weight and delayed nervous system development. Our data indicate that while MAP1B is not essential for survival, it is essential for normal time course development of the murine nervous system. These conclusions are very different from those of a previous MAP1B gene-targeting study (Edelmann, W., M. Zervas, P. Costello, L. Roback, I. Fischer, A. Hammarback, N. Cowan, P. Davis, B. Wainer, and R. Kucherlapati. 1996. Proc. Natl. Acad. Sci. USA. 93: 1270-1275). In this previous effort, homozygotes died before reaching 8-d embryos, while heterozygotes showed severely abnormal phenotypes in their nervous systems. Because the gene targeting event in these mice produced a gene encoding a 571-amino acid truncated product of MAP1B, it seems likely that the phenotypes seen arise from the truncated MAP1B product acting in a dominant-negative fashion, rather than a loss of MAP1B function.

Function of oleic acid on epidermal barrier and calcium influx into keratinocytes is associated with N-methyl D-aspartate-type glutamate receptors.

BACKGROUND: Unsaturated fatty acids from sebum affect calcium dynamics in epidermal keratinocytes, disrupt the barrier function and induce abnormal keratinization. However, the mechanisms of these effects have not been clarified. OBJECTIVES: To investigate the function of unsaturated fatty acids in epidermis. METHODS: Antagonists of calcium channel receptors were applied to mouse skin together with oleic acid. Measurements were made of transepidermal water loss (TEWL), and hyperproliferation was assessed. The effects of the antagonists on calcium influx into cultured normal human keratinocytes and on cytokine production were also evaluated. RESULTS: N-methyl-d-aspartate (NMDA) receptor antagonists such as MK801 and D-AP5 specifically inhibited the increase in TEWL caused by oleic acid, and suppressed keratinocyte hyperproliferation. These compounds also inhibited the increase in the intracellular concentration of calcium ions induced by oleic acid. MK801 suppressed the production of interleukin-1alpha by keratinocytes induced by oleic acid. CONCLUSIONS: Unsaturated fatty acids such as oleic acid might function via NMDA receptors.

Convulsions after ropivacaine 300 mg for brachial plexus block.

A healthy 18-yr-old male (weight 60 kg, height 167 cm), with a history of febrile convulsions in childhood, developed a grand mal convulsion 10 min after the second of two injections of ropivacaine 150 mg, both given incrementally 15 min apart (total 300 mg), for combined axillary/interscalene brachial plexus block. Treatment was with oxygen, lung ventilation, and i.v. midazolam, and the patient made a complete recovery. Arterial plasma ropivacaine concentration 2 min after the onset of convulsions was only 2.13 mg litre(-1), suggesting that this patient was particularly susceptible to local anaesthetic toxicity. Whether sub-clinical EEG changes identified after operation were related to this sensitivity cannot be determined, but review illustrates wide variation in both the dose and the plasma concentration of local anaesthetics associated with systemic toxicity. The UK recommended dose of ropivacaine for brachial plexus block is 225-300 mg according to stature.

Prevalence of Smqnr and plasmid-mediated quinolone resistance determinants in clinical isolates of Stenotrophomonas maltophilia from Japan: novel variants of Smqnr.

Stenotrophomonas maltophilia is an important pathogen in healthcare-associated infections. S. maltophilia may contain Smqnr, a quinolone resistance gene encoding the pentapeptide repeat protein, which confers low-level quinolone resistance upon expression in a heterologous host. We investigated the prevalence of Smqnr and plasmid-mediated quinolone resistance (PMQR) determinants in S. maltophilia isolates from Japan. A total of 181 consecutive and nonduplicate clinical isolates of S. maltophilia were collected from four areas of Japan. The antimicrobial susceptibility profiles for these strains were determined. PCR was conducted for Smqnr and PMQR genes, including qnrA, qnrB, qnrC, qnrS, aac(6')-Ib and qepA. PCR products for Smqnr and aac(6')-Ib were sequenced. For the S. maltophilia isolates containing Smqnr, pulsed-field gel electrophoresis (PFGE) was performed using XbaI. Resistance rates to ceftazidime, levofloxacin, trimethoprim-sulfamethoxazole, chloramphenicol and minocycline were 67.4%, 6.1%, 17.7%, 8.8% and 0%, respectively. The minimum inhibitory concentration required to inhibit the growth of 50% and 90% of organisms were 0.5 and 2 mg/L for moxifloxacin but 1 and 4 mg/L for levofloxacin, respectively. Smqnr was detected in 104 of the 181 S. maltophilia isolates (57.5%), and the most frequent was Smqnr6, followed by Smqnr8 and Smqnr11. Eleven novel variants from Smqnr48 to Smqnr58 were detected. The 24 Smqnr-containing S. maltophilia isolates were typed by PFGE and divided into 21 unique types. Nine S. maltophilia isolates (5.0%) carried aac(6')-Ib-cr. No qnr or qepA genes were detected. This study describes a high prevalence of Smqnr and novel variants of Smqnr among S. maltophilia from Japan. Continuous antimicrobial surveillance and further molecular epidemiological studies on quinolone resistance in S. maltophilia are needed.

Biosynthetic pathway for production of a conjugated dienyl sex pheromone of a Plusiinae moth, Thysanoplusia intermixta.

Virgin females of Thysanoplusia intermixta (Lepidoptera; Noctuidae; Plusiinae) produce (5E,7Z)-5,7-dodecadienyl acetate as a main sex pheromone component. GC-MS analysis of the pheromone glands, which were treated with deuterated hexadecanoic, (Z)-11-hexadecenoic, and (Z)-7-dodecenoic acids, showed incorporation of the label into the dienyl component. Their incorporation rates confirmed that its biosynthesis proceeds in the following order: Delta11-desaturation of a C(16) acyl intermediate, chain shortening to a C(12) compound by beta-oxidation, Delta5-desaturation to produce a 5,7-dienyl system, reduction of the acyl group, and acetylation. These deuterated precursors also converted into a minor pheromone component, (Z)-7-docecenyl acetate, which might be prepared by the same pathway except for the step of Delta5-desaturation. While deuterium incorporation into the dienyl acetate was not observed in the extracts treated with other labeled dodecenoic acids with (E)-5-, (Z)-6-, and (E)-7-double bonds, the corresponding dodecenyl acetates were produced. This result showed low substrate specificity of the enzymes for reduction and acetylation. Labeled (Z)-10-hexadecenoic acid was not converted into a dodecenyl acetate, indicating the high substrate specificity of the enzyme for beta-oxidation.

Renal hypertrophy as a prognostic index for the progression of diabetic renal disease in non-insulin-dependent diabetes mellitus.

The aim of this study is to elucidate the clinical significance of estimating renal size in non-insulin-dependent diabetes mellitus (NIDDM). Renal size was compared in 57 NIDDM patients with persistent normoalbuminuria [group I; 19 cases, albumin excretion rate (AER) < 20 micrograms/min], microalbuminuria (group II; 24 cases, AER = 20-200 micrograms/min), or macroalbuminuria (group III; 14 cases, AER > 200 micrograms/min). Three groups were matched for age and diabetes duration. Renal size was estimated using drip-infusion pyelography according to Simon's method (mean kidney length/height of second lumbar spine and disc; renal ratio, RR). Thirteen patients with persistent microalbuminuria (10 normotensive and 3 hypertensive) were traced during at least 3 years. Angiotensin-converting enzyme inhibitor (enalapril) was used in 11 cases. The results are as follows: (1) Renal size in groups II (RR, 3.47 +/- 0.28; cited as mean +/- SD) and III (3.62 +/- 0.32) significantly increased compared with that in group I (3.26 +/- 0.20) (p < 0.01 and p < 0.001, respectively). No statistical differences could be detected between groups II and III. (2) As a whole, good metabolic (glycosylated hemoglobin, HbA1) and hemodynamic (systolic blood pressure, SBP) control was achieved during the last 12 months (HbA1, 8.4% +/- 0.9%; SBP, 122 +/- 8 mm Hg). There was no significant correlation between RR and creatinine clearance, HbA1, SBP, or diastolic blood pressure during the first and last 12 months. Initial RR significantly correlated with AER during the last 12 months (r = 0.651, p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Enhanced production of saikosaponins by root culture of Bupleurum falcatum L. using two-step control of sugar concentration.

The effect of sugar concentration on the production of saikosaponins was investigated using a root culture of Bupleurum falcatum L. The formation of the lateral roots, which were induced in the presence of indolebutyric acid, was suppressed as the sugar concentration was increased. After the lateral root tips had emerged from the inoculated roots, however, high concentrations of sugar showed no inhibitory effect on the development of the lateral roots. A two-step culture, with 1% sucrose at the beginning of the culture and addition of 6% sucrose at 14 days, when lateral roots have emerged, greatly improved the productivity, affording 0.8 g/l of saikosaponin-a and -d.

Extraction and determination of anionic surfactants with copper (II)-ethylenediamine derivative complexes.

Anionic surfactants, S(-) [where S(-) is dodecyl sulphate (DS) or dodecylbenzenesulphonate (DBS)] were extracted with a series of copper (II)-ethylenediamine derivative complexes, CU(R-en)(2)(2+), where R-en is ethylenediamine (en), N,N'-dimethylethylenediainine (NN'Me(2)en), N,N-dimethylethylenediamine (NNMe(2)en), N,N-diethylethylenediamine (NNE(2)en) or 1,2-cyclohexanediamine (Cyen). The extraction constant of the ion-pair is K(ex) = [Cu(R-en)(2)(2+) . 2S(-)](0)/[Cu(R-en)(2)(2+)][S(-)](2). The constants for extraction of the DS complexes with en, NN'Me(2)en, NNMe(2)en, NNEt(2)en and Cyen into chloroform were found to be log K(ex) = 7.93, 9,19, 8.88, 8.74 and 11.45 (+/- 0.05 at 25 degrees C), respectively. The extractability of the ion-pair Cu(en)(2)(2+) . 2S(-) gave a linear correlation with the acidity of the solvent. The Cu(Cyen)(2)(2+) extraction system was applied to the determination of some anionic surfactants. With use of graphitefurnace atomic-absorption spectrophotometry, a limit of detection of 5mug l . was obtained with a 20-ml sample of river water or sea-water.

A study of the in vitro clinical interaction between lidocaine and premedications using rat liver microsomes.

In this study, we have investigated the relationship between lidocaine metabolism and premedication, i.e., psychotropic and anti-anxiety agents (diazepam, midazolam), hypnotics (pentobarbital, thiamylal), depolarizing muscular relaxants (vecuronium, pancuronium and suxamethonium), an active anti-hypertensive (clonidine) and an H2 receptor antagonist (cimetidine) using rat hepatic microsomes in vitro. Lidocaine metabolism was noncompetitively inhibited by midazolam (Ki=29.0 microM). Thilamylal was a moderate competitive inhibitor of lidocaine metabolism (Ki=77.8 microM). Pentobarbital, diazepam and cimetidine weakly inhibited lidocaine metabolism formation in a concentration-dependent manner at high substrate concentrations. On the other hand, vecuronium, pancuronium, suxamethonium and clonidine did not inhibit lidocaine metabolism over the therapeutic range. These results show that the interaction between lidocaine and midazolam and thiamylal, catalyzed by a similar cytochrome P450, is of potential importance in toxicological and clinical studies.

End-tidal carbon dioxide monitoring during awake blind nasotracheal intubation.

STUDY OBJECTIVE: To test the usefulness of the end-tidal carbon dioxide monitor in facilitating awake blind nasotracheal intubation in patients with potentially difficult airways. DESIGN: Randomized, controlled comparison of regimen. SETTING: Inpatient surgery clinic at a university hospital. PATIENTS: Sixty-one consecutive patients with potentially difficult airways. INTERVENTIONS: After airway anesthesia with 4% lidocaine was administered to all patients, either fentanyl and diazepam (n = 30) or fentanyl alone (n = 31) was given intravenously before the awake blind nasotracheal intubation procedure. MEASUREMENTS AND MAIN RESULTS: End-tidal carbon dioxide concentration, arterial blood pressure, heart rate, and arterial oxygen saturation (by pulse oximeter) were measured in each patient during the awake blind nasotracheal intubation procedure. The day after anesthesia and surgery, each patient was asked to assess the degree of discomfort experienced during the procedure. In 54 of 61 patients, the end-tidal carbon dioxide monitor facilitated awake blind nasotracheal intubation. End-tidal carbon dioxide was significantly higher in patients given both fentanyl and diazepam than in those given fentanyl alone (7.4% +/- 1.4% vs 5.9% +/- 0.9%, respectively; p less than 0.05), but no patient in either group recalled the awake intubation as extremely uncomfortable. CONCLUSIONS: Monitoring of end-tidal carbon dioxide is useful and valuable in both facilitating blind nasotracheal intubation and avoiding profound hypoventilation.

[Preparation and clinical evaluation of orally-disintegrating clonidine hydrochloride tablets for preanesthetic medication].

Orally-disintegrating tablets of clonidine hydrochloride, an alpha 2-adrenergic agonist, were prepared by the method of drying an aqueous suspension. The suspension was prepared using powdered lactose, and the composition ratio was 2:1 (powdered lactose: 0.048% clonidine hydrochloride solution). The suspension was dried under 4 +/- 1 degrees C (72 +/- 15% R.H.). We obtained tablets containing clonidine hydrochloride (40 micrograms/tablet). Physical properties of the tablets were as follows: hardness was 4.0 kgf, and disintegration time was 41.7 s (in vitro). In the clinical use, 8 patients, aged 1-2 year and weighing 9-11 kg, received approximately 4 micrograms/kg body weight as clonidine hydrochloride. The tablet was administered 90 min before entering the operating room. All patients were willing to accept the tablet. The quality of separation from parents, sedation and a mask acceptance were excellent on all patients. These results suggest that the orally-disintegrating tablet of clonidine hydrochloride was useful in a clinical situation for the preanesthetic medication of pediatric patients aged 1-2 year.

[Venous air embolism following repositioning from sitting to supine].

We have experienced a patient in whom venous air embolism reoccurred, when the patient's position was changed from sitting to supine. A 40 year old male with Arnold-Chiari malformation underwent suboccipital decompression and cervical laminectomy under the sitting position. During surgery, three episodes of venous air embolism were detected by high pitched sound through precordial ultrasound Doppler stethoscope, an abrupt increase in pulmonary arterial pressure, a decrease in end-tidal carbon dioxide concentration; and a small amount of bubbled air was removed from the central venous catheter. At the end of surgery when the patient was turned to supine position, the signs of venous air embolism reappeared and 3 ml of bubbled air was also removed. This case suggests that there is some remaining air in the large veins of the upper part of the body once the air embolism has occurred during sitting position and thus we need to confirm that no air is left in the large veins before repositioning. We should be cautious of reoccurrence of venous air embolism whenever patient's position is changed.

[Central venous access via the distal femoral vein using ultrasound-guidance].

We used a new method for central venous (CV) access via the distal femoral vein using ultrasound guidance in two cases. In the first case, because of multiple catheter punctures for hemodialysis previously, femoral catheter placement was impossible using a standard landmark technique. In the second case of laryngoplasty, it was also impossible to place a CV catheter at usual groin sites because of extensive mycosis. In these two cases, we attempted CV catheterization via the distal femoral vein at the femur (10 cm from the inguinal ligament) by using ultrasound guidance. In both cases the catheter placement was easy and took a short time. No complication due to puncture and catheterization was observed. CV access via the femoral vein in the groin has been the first-choice for the patients undergoing neuro- or neck-surgery. However, the femoral CV catheters at inguinal site has been associated with higher incidence of catheter infection than the subclavian or internal jugular vein. These methods have a potential for decrease in catheter infection rate. These two case reports suggest that the CV catheterization at distal femoral site by ultrasound-guidance is useful as a new method of CV access.

[Hemodynamic effects of lung inflation during bilateral and single lung ventilation--a clinical investigation].

Hemodynamic changes during positive airway pressure ventilation is well known. To compare changes of hemodynamic variables during one-lung inflation with those during two-lung inflation, we studied the effects of lung inflation on hemodynamic changes in 15 anesthetized patients who were intubated endobronchially. When the airway pressure was increased from 0 cmH2O to 10, 20, 30 cmH2O, systolic pressure decreased gradually and central venous pressure increased during both two-lung and one-lung inflations (P less than 0.05). During one-lung inflation, the decrease in arterial pressure relative to apneic arterial pressure was significantly less than those during two-lung inflation at each level of airway pressure (P less than 0.05). During one-lung inflation, central venous pressure which was higher relative to apneic central venous pressure, and was less than that during two-lung inflation at 30 cmH2O (P less than 0.05). Heart rate was unchanged during both two and one-lung inflations compared with apneic heart rate. We conclude that during one-lung inflation, systolic pressure and central venous pressure are influenced less by the increased airway pressure than during two-lung inflation. The results indicate that during one lung ventilation, lungs inflated with clinically accepted levels of airway pressure do not depress the systemic circulation, but when the airway pressure during one-lung inflation (like a leak test) exceeded over 30 cmH2O, a significant depression of the systemic circulation occurs.

[Heart rate response to intravenous atropine during cervical and lumbar epidural anesthesia].

The authors evaluated the effect of cervical and lumbar epidural anesthesia on the heart rate response to intravenous atropine 0.01 mg.kg-1 in conscious humans with cervical epidural anesthesia (n = 40), with lumbar epidural anesthesia (n = 15) and without epidural anesthesia (n = 25). During cervical and lumbar epidural anesthesia using 1.5% lidocaine, levels of loss of cold sensation were C3-T7 and T7-S1, respectively. Heart rate increased by 14 +/- 10% (mean +/- SD) and 20 +/- 14% after intravenous atropine 0.01 mg.kg-1 in the patients with cervical and lumbar epidural anesthesia, respectively. These magnitudes of positive chronotropic effects were significantly less as compared with those in the patients without epidural anesthesia (32 +/- 11%). Nine of 40 patients (23%) with cervical epidural anesthesia showed heart rate increases of less than 3 beats.min-1 following atropine 0.01 mg.kg-1. And 30 of 40 patients (75%) required supplementary atropine 0.01 mg.kg-1 to increase heart rate for more than 20 beats.min-1 from baseline values. The present study suggests that the heart rate response to intravenous atropine is blunted in patients during cervical and lumbar epidural anesthesia, and that a larger dose of intravenous atropine may be required to accelerate the heart rate in most patients during cervical epidural anesthesia.

[Anesthetic management for left ventricular assist device implantation in patients waiting for heart transplantation].

We report the anesthetic management of patients with dilated cardiomyopathy who underwent left ventricular assist device implantation (LVAD). Anesthesia was induced and maintained with midazolam and fentanyl. Transesophageal echocardiography (TEE) and a PA catheter were useful for hemodynamic monitoring and management of the patients. Furthermore, TEE is useful for the early detection of inflow of the air which is absorbed by negative pressure derived from high LVAD support pressure. On starting LVAD support, evaluation of right ventricular function and treatment for right ventricular failure were important and necessary for the patients. Added to conventional therapy using catecholamines, inhaled nitric oxide may provide a favorable effect for right ventricular failure.