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INTRODUCTION: We conducted an investigator-initiated clinical trial in which remimazolam was used to achieve sedation in patients undergoing colonoscopies. METHODS: This multicenter, double-blind, placebo-controlled, phase III investigator-initiated trial included patients who underwent colonoscopy under sedation with remimazolam (initial dose: 3 mg; additional dose: 1 mg) or normal saline (placebo). The primary endpoint of the study was the successful sedation rate during colonoscopy, defined as achieving a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of ≤4 before the procedure, maintaining this score throughout colonoscopy, and requiring no more than five additional drug doses per 15 min. RESULTS: The sedation success rate was 95.0% (38/40 patients) in the remimazolam group and 0.0% (0/11 patients) in the placebo group (p < 0.01). The time from the end of procedure to regaining consciousness was 0.0 (interquartile range: 0.0-0.0) min in both groups. The time from the end of the procedure to ambulation was 5.0 (interquartile range: 0.0-10.0) min in the remimazolam group and 0.0 (interquartile range: 0.0-0.0) min in the placebo group (p = 0.02). Serious adverse events were not observed. CONCLUSION: The use of remimazolam to achieve sedation in Japanese patients undergoing colonoscopy was more effective than placebo.
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OBJECTIVES: To assess the effectiveness of remimazolam against normal saline (placebo) as a sedative agent for endoscopy in a multicenter, randomized, double-blind, investigator-initiated phase III controlled trial. METHODS: We included 48 Japanese patients undergoing upper gastrointestinal endoscopy. For the procedure, an initial remimazolam dose of 3 mg and additional doses of 1 mg were administered, as determined in the phase II clinical study. The primary study end-point was the successful sedation rate during gastrointestinal endoscopy, determined as a Modified Observer's Assessment of Alertness/Sedation score ≤4 before the start of endoscopy, the completion of gastrointestinal endoscopy, and two or fewer additional doses per 6 min. RESULTS: The successful endoscopy sedation rates were 91.9% and 9.1% in the remimazolam and placebo groups, respectively (P < 0.01). The time from the end of endoscopy to arousal was 0.0 (0.0-0.0) min for both groups. The number of additional doses required to achieve sedation was lower in the remimazolam group than that in the placebo group (P < 0.01). CONCLUSIONS: Remimazolam demonstrated a significantly higher sedation effect during upper gastrointestinal endoscopy in Japanese patients with safe and fast recovery compared with placebo.
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Recent advances in neuromuscular monitors have facilitated the development of a new electromyographic module, AF-201P™. The purpose of this study was to investigate the relationship between post-tetanic counts (PTCs) assessed using the AF-201P™ and the acceleromyographic TOF Watch SX™ during rocuronium-induced deep neuromuscular block. Forty adult patients consented to participate in this study. The integrated AF-201P™ stimulating and sensing electrode was placed over the ulnar nerve on the distal volar forearm and the belly of the abductor digiti minimi muscle of one arm. The TOF Watch SX™ was applied with the provided hand adaptor on the opposite arm, to observe twitch responses of the adductor pollicis muscle. After stabilization of train-of-four (TOF) responses, rocuronium 0.9 mg kg-1 was administered intravenously. Then, PTCs were observed every 3 min using both monitors. Whenever the TOF count was detected with the TOF Watch SX™, rocuronium 0.2 mg kg-1 was administered, and successive PTC measurements were continued. A total of 1732 paired PTC data points were obtained and analyzed. Regression analysis showed no significant difference in PTCs between the two monitors (PTCs measured by the TOF Watch SX™ = 0.78·PTCs measured by AF-201P™ + 0.21, R = 0.56). Bland-Altman analysis also showed acceptable ranges of bias [95% CI] and limits of agreement (0.3 [0.2 to 0.5] and - 4.6 to 5.3) for the PTCs. The new EMG module, AF-201P™, showed reliable PTCs during deep neuromuscular block, as well as the TOF Watch SX™.
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Bloqueo Neuromuscular , Fármacos Neuromusculares no Despolarizantes , Adulto , Androstanoles , Periodo de Recuperación de la Anestesia , Humanos , Estudios Prospectivos , RocuronioRESUMEN
PURPOSE: Perioperative analgesia during thoracotomy is often achieved by combining paravertebral block (PVB) with general anesthesia (GA). Functional near-infrared spectroscopy (NIRS) can detect changes in cerebral oxygenation resulting from nociceptive stimuli in the awake state or under sedation. We used NIRS to measure changes in cerebral blood flow provoked by thoracotomy incision made under GA and determine how these changes were influenced by supplementation of GA with PVB. METHODS: Thirty-four patients undergoing elective thoracotomy were enrolled. Patients were randomly assigned to a group receiving only GA, or GA combined with PVB (GA + PVB). Changes in cerebral oxygenated hemoglobin (ΔO2Hb), deoxygenated-Hb (ΔHHb), and total-Hb (ΔtotalHb) were evaluated by NIRS as surgery began. RESULTS: In the GA group, ΔO2Hb was significantly higher in the hemisphere contralateral to the side of surgery when the incision was made and 2 min after incision compared with the ipsilateral side (start of surgery, P < 0.01; 2 min, P < 0.05). In contrast, there were no significant changes in the ΔO2Hb at any of the time points in the GA + PVB group. Comparable with ΔO2Hb, the concentration of ΔtotalHb was significantly higher in the contralateral hemisphere in the GA group at the start of surgery (P < 0.05). CONCLUSIONS: Changes in the cerebral O2Hb concentration were detected by NIRS immediately after surgical incision under GA, but not in the presence of a PNB. NIRS could be used to monitor surgical pain. PVB inhibited changes in oxygenation induced by incision-provoked pain.
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Anestesia General/métodos , Bloqueo Nervioso/métodos , Oxígeno/metabolismo , Toracotomía/métodos , Anciano , Femenino , Hemoglobinas/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/epidemiología , Espectroscopía Infrarroja CortaRESUMEN
PURPOSE: Acute kidney injury (AKI) is one of the critical complications after cardiac surgery. In the kidney, angiotensin II (Ang II) is formed by independent mechanisms, and activity of the intrarenal renin-angiotensin-aldosterone (RAAS) system contributes to the progression of kidney damage. Although atrial natriuretic peptide (ANP) exerts protective effects against renal injury by inhibiting the RAAS, the mechanisms of this effect have not been completely clarified. We investigated how human ANP (hANP) could prevent renal damage induced by cardiopulmonary bypass. METHODS: Forty-eight patients undergoing cardiac surgery were divided into two groups, with and without hANP infusion. Urinary angiotensinogen, neutrophil gelatinase-associated lipocalin (NGAL) and L-type fatty acid-binding protein (L-FABP) were measured during and after surgery in both groups. Plasma renin activity, Ang II, aldosterone and serum creatinine were also measured. RESULTS: Urinary angiotensinogen levels in the hANP group were significantly lower than in the non-hANP group after cardiopulmonary bypass surgery, at the end of surgery and 3 h after surgery. At 3 h after surgery, urinary NGAL levels in the hANP and non-hANP groups were 371.1 ± 413.6 and 761.4 ± 437.8 µg/gCr, respectively (p < 0.01). Urinary L-FABP levels at the end of surgery in the hANP and non-hANP groups were 238.8 ± 107.4 and 573.9 ± 370.1 µg/gCr, respectively (p < 0.01). Moreover, hANP seemed to significantly reduce the incidence of postoperative AKI. CONCLUSIONS: hANP demonstrated renal protective effects during cardiac surgery, and could possibly reduce the incidence of AKI after ischemia-reperfusion surgery. Moreover, this protective effect of hANP is likely induced by inhibition of the intrarenal RAAS.
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Lesión Renal Aguda/prevención & control , Factor Natriurético Atrial/farmacología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Anciano , Angiotensina II/sangre , Puente Cardiopulmonar/efectos adversos , Proteínas de Unión a Ácidos Grasos/orina , Femenino , Humanos , Riñón/efectos de los fármacos , Masculino , Persona de Mediana Edad , Periodo PosoperatorioRESUMEN
We report a case of sudden shock during caesarean section under combined spinal epidural anesthesia. The patient was a 29-year-old woman. During the operation vital signs had been almost stable until a female-baby was born. But after the delivery of the placenta, the patient developed an episode of coughing and dyspnea followed by unconsciousness and bradycardia. She was given adrenaline and intubated, appearing ventricular fibrillation on a EKG. Cardiopulmonary resuscitation was immediately started and sinus rhythm returned. Hypotension followed and a small dose of adrenaline was infused for three days. She made good progress and was discharged without significant sequela. Cardiopulmonary collapse type of amniotic fluid embolism (AFE) is doubtful in this case. The necessity of rapid and appropriate treatment for emergency obstetric cases was discussed.
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Anestesia Raquidea/efectos adversos , Cesárea , Embolia de Líquido Amniótico/terapia , Choque/inducido químicamente , Adulto , Bradicardia , Reanimación Cardiopulmonar , Disnea , Embolia de Líquido Amniótico/inducido químicamente , Epinefrina/uso terapéutico , Femenino , Humanos , Complicaciones Intraoperatorias , Parto , Embarazo , Vasoconstrictores/uso terapéuticoRESUMEN
BACKGROUND: Ischemia-reperfusion (I/R) injury is one of the most important pathologic processes causing acute kidney injury. Human atrial natriuretic peptide (hANP) has various effects, including renal protection. The purpose of the present work was to study the effects of intrarenal angiotensin II (Ang II) and investigate the potential of hANP to prevent kidney injury. MATERIALS AND METHODS: Male Sprague-Dawley rats were divided into three groups as follows: (1) sham; (2) I/R (30 min of bilateral renal ischemia followed by 6 h reperfusion); and (3) I/R + hANP (I/R injury + continuous intravenous infusion of hANP at 0.025 µg/kg/min). After 6 h of reperfusion, both renal and plasma Ang II concentrations were measured. Urinary angiotensinogen and neutrophil gelatinase-associated lipocalin were measured before ischemia and 2, 4, and 6 h after reperfusion. To evaluate the renal-protective effects of hANP, serum creatinine was determined 6 and 24 h after reperfusion. In addition, mitochondrial oxygen consumption in kidney cortex was measured in the presence of Ang II and hANP. RESULTS: Renal Ang II concentrations were 24.5 ± 3.9 and 14.2 ± 3.4 pg/mg renal weight in the I/R and I/R + hANP groups, respectively. Urinary angiotensinogen and neutrophil gelatinase-associated lipocalin excretions were elevated after I/R injury. Treatment with hANP significantly attenuated this effect after 4 and 6 h. Oxygen consumption in renal mitochondria increased with the addition of Ang II, which was also attenuated by hANP. CONCLUSIONS: Production of intrarenal Ang II was attenuated by hANP, indicating a potential to diminish renal I/R injury.
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Lesión Renal Aguda/prevención & control , Angiotensina II/metabolismo , Factor Natriurético Atrial/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Daño por Reperfusión/prevención & control , Lesión Renal Aguda/metabolismo , Proteínas de Fase Aguda/orina , Angiotensinógeno/orina , Animales , Riñón/metabolismo , Lipocalina 2 , Lipocalinas/orina , Masculino , Mitocondrias/metabolismo , Consumo de Oxígeno , Complicaciones Posoperatorias/metabolismo , Proteínas Proto-Oncogénicas/orina , Ratas Sprague-Dawley , Daño por Reperfusión/metabolismoRESUMEN
Intrathecal (i.t.) administration of pituitary adenylate cyclase-activating polypeptide (PACAP) induces long-lasting nociceptive behaviors for more than 60 min in mice, while the involvement of PACAP type1 receptor (PAC1-R) has not been clarified yet. The present study investigated signaling mechanisms of the PACAP-induced prolonged nociceptive behaviors. Single i.t. injection of a selective PAC1-R agonist, maxadilan (Max), mimicked nociceptive behaviors in a dose-dependent manner similar to PACAP. Pre- or post-treatment of a selective PAC1-R antagonist, max.d.4, significantly inhibited the nociceptive behaviors by PACAP or Max. Coadministration of a protein kinase A inhibitor, Rp-8-Br-cAMPS, a mitogen-activated protein kinase/extracellular signal-regulated kinase (ERK) kinase inhibitor, PD98059 or a c-Jun N-terminal kinase (JNK) inhibitor, SP600125, significantly inhibited the nociceptive behaviors by Max. Immunohistochemistry and immunoblotting analysis revealed that spinal administration of Max-induced ERK phosphorylation and JNK phosphorylation, and also augmented an astrocyte marker, glial fibrillary acidic protein in mouse spinal cord. Furthermore, an astroglial toxin, l-α-aminoadipate, significantly attenuated the development of the nociceptive behaviors and ERK phosphorylation by Max. These results suggest that the activation of spinal PAC1-R induces long-lasting nociception through the interaction of neurons and astrocytes.
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Astrocitos/fisiología , Conducta Animal/fisiología , Nocicepción/fisiología , Receptores del Polipéptido Activador de la Adenilato-Ciclasa Hipofisaria/fisiología , Transducción de Señal , Médula Espinal/citología , Médula Espinal/fisiología , Animales , Masculino , Ratones EndogámicosRESUMEN
BACKGROUND: The wound healing process following acute inflammation after surgery is impaired in diabetes. Altered macrophage functions are linked to delayed tissue repair and pain development in diabetes. Although peroxisome proliferator-activated receptor (PPAR)-γ agonists are used to treat diabetes, their postoperative analgesic effects in diabetes have not been evaluated. METHODS: The PPARγ agonist rosiglitazone (rosi) was injected at the incision site of diabetic (db/db) mice with resolvin (Rv) D1, a lipid mediator involved in resolution of inflammation. Pain-related behavior, neutrophil infiltration, phagocytosis, and macrophage polarity were assessed for 7 days postoperatively. RESULTS: Rosiglitazone and RvD1 alleviated mechanical hyperalgesia in db/db (db) mice, whereas rosiglitazone alone did not alter mechanical thresholds on days 4 (db rosi + RvD1 vs. db rosi: 0.506 ± 0.106 vs. 0.068 ± 0.12) and 7 (0.529 ± 0.184 vs. 0.153 ± 0.183) after incision (n = 10 per group). In control m/m mice, the rosiglitazone-induced analgesic effects were reversed by knockdown with arachidonate 5-lipoxygenase small interfering RNA, but these were restored by addition of RvD1. In db/db mice treated with rosiglitazone and RvD1, local infiltration of neutrophils was markedly reduced, with an associated decrease in total TdT-mediated dUTP nick-end labeling cells. Acceleration of rosiglitazone-induced phenotype conversion of infiltrated macrophages from M1 to M2 was impaired in db/db mice, but it was effectively restored by RvD1 in db/db wounds. CONCLUSIONS: In diabetes, exogenous administration of RvD1 is essential for PPARγ-mediated analgesia during development of postincisional pain. Resolution of inflammation accelerated by RvD1 might promote PPARγ-mediated macrophage polarization to the M2 phenotype.
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Diabetes Mellitus Tipo 2/complicaciones , Ácidos Docosahexaenoicos/farmacología , Inflamación/tratamiento farmacológico , PPAR gamma/agonistas , Dolor Postoperatorio/tratamiento farmacológico , Tiazolidinedionas/farmacología , Analgesia/métodos , Animales , Diabetes Mellitus Experimental/complicaciones , Modelos Animales de Enfermedad , Hipoglucemiantes/farmacología , Macrófagos/efectos de los fármacos , Masculino , Ratones , Dolor Postoperatorio/complicaciones , RosiglitazonaRESUMEN
BACKGROUND: Rocuronium bromide (Rb) is a rapid onset, intermediate-acting neuromuscular blocking agent that is suitable for continuous administration. The appropriate rate of rocuronium administration is, however, difficult to determine due to large interindividual differences in sensitivity to rocuronium. The aim of this study was to clarify whether the simulated rocuronium concentration at the time of recovery to %T1 > 0 % after the initial administration of rocuronium is a good indicator of optimal effect-site concentrations during continuous rocuronium administration. METHODS: Twenty-one patients were anesthetized with propofol. After induction, Rb 0.6 mg/kg was administered intravenously, and nerve stimulation using the single stimulation mode was conducted every 15 s. When %T1 recovered to >0 % after the initial administration of Rb, the effect-site concentration of rocuronium, calculated by pharmacokinetic simulation with Wierda's set of parameters, was recorded and defined as the recovery concentration (Rb r.c.). The administration rate of rocuronium was adjusted to maintain the Rb r.c. during surgery. Rb administration was discontinued just before the end of surgery, and the recovery time until %T1 > 25 % was recorded. Plasma Rb concentrations were measured at 1 and 3 h after the initiation of continuous Rb administration. RESULT: The mean Rb r.c. was 1.56 ± 0.35 µg/ml, with minimum and maximum values of 1.09 and 2.08 µg/ml, respectively. The %T1 did not increase above 10 % in any of the patients during continuous administration of Rb, and the recovery period to %T1 > 25 % ranged from 9 to 29 min. The effect-site concentrations of Rb calculated with Wierda's parameters significantly correlated with plasma concentrations (P < 0.01) at both 1 and 3 h after the initial administration of Rb. CONCLUSION: The results suggest that our method may be one of the most reliable protocols for the continuous administration of Rb described to date for maintaining suitable muscle relaxation during surgery without excessively prolonged effects.
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Androstanoles/administración & dosificación , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Piperidinas/administración & dosificación , Propofol/administración & dosificación , Adulto , Anciano , Anestesia/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Relajación Muscular/efectos de los fármacos , Remifentanilo , RocuronioRESUMEN
BACKGROUND: Using an algorithm by which the effect-site concentration of propofol (esTEC) necessary for BIS level set from information input from BIS monitor and TCI pump is estimated, the effect of remifentanil on esTEC was investigated. METHODS: In 14 abdominal/thoracic surgical patients managed under total intravenous anesthesia with propofol and remifetanil, the distribution of relation between the effect-site concentration of remifetanil and remifentanil esTEC was analyzed in a retrospective manner. RESULTS: While the propofol esTEC decreased in accordance with the increase of the effect-site concentration of remifetanil, the effect-site concentration of propofol esTEC45 for maintaining BIS 45 became within a certain range and with less dispersion when the concentration of remifetanil exceeded 10 ng x ml(-1). CONCLUSIONS: A mutual interaction was observed between propofol esTEC and remifetanil. For anesthetic management with less variation in BIS levels, it was considered that 10 ng x ml(-1) or higher of the effect-site concentration of remifetanil would be necessary.
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Anestésicos Intravenosos/administración & dosificación , Piperidinas/administración & dosificación , Propofol/administración & dosificación , Combinación de Medicamentos , Sinergismo Farmacológico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Remifentanilo , Estudios RetrospectivosRESUMEN
A 20-year-old man diagnosed as idiopathic scoliosis with Cobb angle 146 degrees was scheduled for two-stage operations. Anterior dissection of the thoracic vertebra in the left lateral decubitus position, and the placement of pedicle screws in the prone position were performed as the first-stage operation. During surgery, the patient developed liver contusion with ascites, probably due to hepatic compression placed between vertebrae and operating table in the prone position. In the second operation for posterior spinal fusion, the occurrence of liver contusion was prevented by performing abdominal ultrasonography before and after surgery, and monitoring AST/ALT during anesthesia as the indicators of liver contusion. Intraoperative management for organ protection is required during anesthesia in patients with idiopathic scoliosis associated with thoracic deformity.
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Contusiones/cirugía , Hígado/cirugía , Procedimientos Neuroquirúrgicos , Escoliosis/cirugía , Contusiones/etiología , Humanos , Hígado/diagnóstico por imagen , Hígado/lesiones , Masculino , Procedimientos Neuroquirúrgicos/efectos adversos , Complicaciones Posoperatorias , Postura , Escoliosis/complicaciones , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
Chilaiditi syndrome is assosiated with hepatodiaphragmatic interposition of the colon and the small intestines. We anesthetized 2 patients with Chilaiditi syndrome. A 62-year-old woman with interposition of the intestine was scheduled for right femoral fibrosarcoma resection. She had been medicated for schizophrenia. Total intravenous anesthesia was induced and maintained. Another patient an 81-year-old man with interposition of the colon, was scheduled for transurethral resection of a bladder tumor. He was anesthetized with spinal anesthesia. In both cases, there was no cardiovascular complication or digestive disorder during the perioperative period.
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Anestésicos/uso terapéutico , Síndrome de Chilaiditi , Anciano de 80 o más Años , Síndrome de Chilaiditi/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo Perioperatorio , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Macrophage infiltration to inflammatory sites promotes wound repair and may be involved in pain hypersensitivity after surgical incision. We recently reported that the development of hyperalgesia during chronic inflammation is regulated by macrophage polarity, often referred to as proinflammatory (M1) or anti-inflammatory (M2) macrophages. Although opioids such as morphine are known to alter the inflammatory milieu of incisional wounds through interactions with immunocytes, the macrophage-mediated effects of morphine on the development of postincisional pain have not been well investigated. In this study, we examined how morphine alters pain hypersensitivity through phenotypic shifts in local macrophages during the course of incision-induced inflammation. RESULTS: Local administration of morphine in the early phase, but not in the late phase alleviated mechanical hyperalgesia, and this effect was reversed by clodronate-induced peripheral depletion of local macrophages. At the morphine-injected incisional sites, the number of pro-inflammatory F4/80+iNOS+M1 macrophages was decreased during the course of pain development whereas increased infiltration of wound healing F4/80+CD206+M2 macrophages was observed during the early phase. Morphine increased the gene expression of endogenous opioid, proenkephalin, and decreased the pronociceptive cytokine, interleukin-1ß. Heme oxygenase (HO)-1 promotes the differentiation of macrophages to the M2 phenotype. An inhibitor of HO-1, tin protoporphyrin reversed morphine-induced analgesic effects and the changes in macrophage phenotype. However, local expression levels of HO-1 were not altered by morphine. Conversely, cyclooxygenase (COX)-2, primarily produced from peripheral macrophages in acute inflammation states, was up-regulated in the early phase at morphine-injected sites. In addition, the analgesic effects and a phenotype switching of infiltrated macrophages by morphine was reversed by local administration of a COX inhibitor, indomethacin. CONCLUSIONS: Local administration of morphine alleviated the development of postincisional pain, possibly by altering macrophage polarity at the incisional sites. A morphine-induced shift in macrophage phenotype may be mediated by a COX-2-dependent mechanism. Therefore, µ-opioid receptor signaling in macrophages may be a potential therapeutic target during the early phase of postincisional pain development.
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Analgésicos Opioides/uso terapéutico , Polaridad Celular/efectos de los fármacos , Ciclooxigenasa 2/metabolismo , Macrófagos/efectos de los fármacos , Morfina/uso terapéutico , Dolor/tratamiento farmacológico , Transducción de Señal/efectos de los fármacos , Animales , Modelos Animales de Enfermedad , Edema/tratamiento farmacológico , Edema/etiología , Inhibidores Enzimáticos/farmacología , Regulación de la Expresión Génica/efectos de los fármacos , Regulación de la Expresión Génica/fisiología , Miembro Posterior/lesiones , Hiperalgesia/tratamiento farmacológico , Hiperalgesia/etiología , Masculino , Ratones , Ratones Endogámicos C57BL , Dolor/etiología , Dolor/patología , Umbral del Dolor/efectos de los fármacos , Heridas Punzantes/complicacionesRESUMEN
BACKGROUND: Postanesthetic shivering can be triggered by surgical stress and several aspects of anesthetic management and is frequently preceded by a decrease in peripheral blood flow due to thermoregulatory vasoconstriction. As perfusion index correlates with peripheral blood flow, we examined whether perioperative perfusion index, measured using pulse oximetry, might be correlated with postanesthetic shivering. METHODS: Twenty-eight patients presenting for elective abdominal surgery were enrolled. Core (esophagus) and peripheral (finger) temperatures and perfusion index were recorded in the perioperative periods. Correlations between perfusion index and peripheral temperature and core-to-peripheral temperature gradient were then explored. Plasma levels of epinephrine and norepinephrine were also measured. The extent of shivering was graded after emergence from anesthesia. RESULTS: Perfusion index declined before emergence from anesthesia in patients who then developed postanesthetic shivering. This coincided with the time at which the difference between core and peripheral temperature became dissociated and peripheral temperature declined. Perioperative perfusion index was correlated with peripheral temperature and peripheral-core temperature gradient. Perfusion index at closure of the peritoneum predicted postanesthetic shivering and was significantly correlated with the extent of shivering. Plasma levels of both epinephrine and norepinephrine were significantly elevated after shivering events. CONCLUSIONS: Perfusion index was significantly lower in patients with postanesthetic shivering before emergence from anesthesia, indicating that measurement of perfusion index during and before the end of anesthesia might be a useful means of predicting postanesthetic shivering.
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Anestesia/efectos adversos , Anestésicos/efectos adversos , Tiritona/efectos de los fármacos , Adulto , Anciano , Anestésicos/farmacología , Epinefrina/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Norepinefrina/sangre , Oximetría/métodos , Vasoconstricción/efectos de los fármacosRESUMEN
We present a patient with atrial fibrillation (AF) in whom a left atrial (LA) thrombus might have formed during laparotomy despite bridging anticoagulation therapy. No evidence of thrombus was detected by transesophageal echocardiography (TEE) at the start of surgery; however, a thrombus measuring 13 × 10 mm was found in the LA appendage by the end of the procedure, suggesting that thrombus might develop intraoperatively in patients with AF even when bridging anticoagulation is properly established. Intraoperative TEE can assist in detecting intracardiac thrombus in patients with AF regardless of their anticoagulation status and provides a tool for intervention to prevent systemic embolization.
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Fibrilación Atrial/tratamiento farmacológico , Ecocardiografía Transesofágica/métodos , Trombosis/diagnóstico por imagen , Anciano , Anticoagulantes/administración & dosificación , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/patología , Humanos , Laparotomía/métodos , Masculino , Trombosis/etiologíaRESUMEN
BACKGROUND: Anesthesia may influence oxidative stress responses to surgical stress during surgery. We performed a prospective study to investigate the impact of anesthesia on oxidative stress responses between patients receiving ropivacaine-based epidural anesthesia and patients receiving remifentanil-based general anesthesia METHODS: Plasma levels of oxidative stress-related substances such as superoxide dismutase (SOD) and myeloperoxidase were measured during anesthesia in patients receiving ropivacaine-based epidural anesthesia (E group) and patients receiving remifentanil-based general anesthesia (R group). RESULTS: SOD, which catalyzes the reduction of superoxide anions to hydrogen peroxide and has anti-oxidative effects, was significantly lower in E group at the end of surgery whereas the levels of myeloperoxydase were not different between the groups. Plasma levels of adrenaline and noradrenaline were significantly higher in R group than E groups after surgery. CONCLUSIONS: Although activation of sympathetic nervous system was effectively inhibited by epidural anesthesia. SOD level was low in E group. Remifentanil might directly increase SOD, independent of sympathetic nervous system.
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Amidas , Anestesia Epidural , Anestesia General , Anestésicos Locales , Antioxidantes/análisis , Procedimientos Quirúrgicos Ginecológicos , Estrés Oxidativo/fisiología , Peroxidasa/sangre , Piperidinas , Superóxido Dismutasa/sangre , Adulto , Anciano , Biomarcadores/sangre , Epinefrina/sangre , Femenino , Humanos , Periodo Intraoperatorio , Persona de Mediana Edad , Norepinefrina/sangre , Remifentanilo , RopivacaínaRESUMEN
BACKGROUND: Efficacy and safety of sugammadex in reversing neuromuscular block induced by rocuronium or vecuronium were investgated in Japanese patients. METHODS: We studied 98 Japanese patients undergoing surgery requiring general anesthesia. Patients were allocated randomly to receive intubation dose of rocuronium or vecuronium. During surgery, patients received additional doses of rocuronium or vecuronium for maintenance of moderate block. At T2 reappearance sugammadex 0-4.0 mg . kg-1 was administered. The neuromuscular block was monitored with acceleromyography using TOF stimuli. Sevoflurane was administered to all treatment groups after intubation. RESULTS: For the rocuronium-induced neuromuscular block, the mean recovery time of the T4/T1 ratio to 0.9 decreased from 82.1 min in the placebo group to 1.8 min in the 4.0 mg . kg-1 sugammadex group. For the vecuronium-induced neuromuscular block, it decreased from 83.2 min in the placebo group to 2.1 min in the sugammadex 4.0 mg . kg-1 group. Plasma concentrations of sugammadex were approximately dose proportional over the dose range of 0.5 to 4.0 mg . kg-1 and independent of the neuromuscular blocking agents used. No clinical evidence of recurarization or residual curarization was observed. CONCLUSIONS: The efficacy and safety of sugammadex were confirmed in Japanese surgical patients.
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Androstanoles/antagonistas & inhibidores , Periodo de Recuperación de la Anestesia , Anestesia General , Bloqueo Neuromuscular , Fármacos Neuromusculares no Despolarizantes/antagonistas & inhibidores , Bromuro de Vecuronio/antagonistas & inhibidores , gamma-Ciclodextrinas/farmacología , Adulto , Androstanoles/administración & dosificación , Pueblo Asiatico , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Rocuronio , Sugammadex , Bromuro de Vecuronio/administración & dosificación , Adulto Joven , gamma-Ciclodextrinas/administración & dosificaciónRESUMEN
Hibernation and torpor are not passive responses caused by external temperature drops and fasting but are active brain functions that lower body temperature. A population of neurons in the preoptic area was recently identified as such active torpor-regulating neurons. We hypothesized that the other hypothermia-inducing maneuvers would also activate these neurons. To test our hypothesis, we first refined the previous observations, examined the brain regions explicitly activated during the falling phase of body temperature using c-Fos expression, and confirmed the preoptic area. Next, we observed long-lasting hypothermia by reactivating torpor-tagged Gq-expressing neurons using the activity tagging and DREADD systems. Finally, we found that about 40-60% of torpor-tagged neurons were activated by succeeding isoflurane anesthesia and by icv administration of an adenosine A1 agonist. Isoflurane-induced and central adenosine-induced hypothermia is, at least in part, an active process mediated by the torpor-regulating neurons in the preoptic area.
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Adenosina , Isoflurano , Neuronas , Área Preóptica , Animales , Área Preóptica/efectos de los fármacos , Área Preóptica/metabolismo , Isoflurano/farmacología , Isoflurano/administración & dosificación , Adenosina/administración & dosificación , Adenosina/farmacología , Adenosina/metabolismo , Neuronas/efectos de los fármacos , Neuronas/metabolismo , Neuronas/fisiología , Masculino , Anestésicos por Inhalación/farmacología , Anestésicos por Inhalación/administración & dosificación , Temperatura Corporal/efectos de los fármacos , Temperatura Corporal/fisiología , Hipotermia/inducido químicamente , Hipotermia/metabolismo , Letargo/efectos de los fármacos , Ratones , Proteínas Proto-Oncogénicas c-fos/metabolismoRESUMEN
We recently showed using prepro-orexin knockout (ORX-KO) mice and orexin neuron-ablated (ORX-AB) mice that orexin neurons in the hypothalamus, but not orexin peptides per se, are indispensable for stress-induced thermogenesis. To examine whether orexin neurons are more generally involved in central thermoregulatory mechanisms, we applied other forms of thermogenic perturbations, including brain prostaglandin E2 (PGE2) injections which mimic inflammatory fever and environmental cold exposure, to ORX-KO mice, ORX-AB mice and their wild-type (WT) litter mates. ORX-AB mice, but not ORX-KO mice, exhibited a blunted PGE2-induced fever and intolerance to cold (5°C) exposure, and these findings were similar to the results previously obtained with stress-induced thermogenesis. PGE2-induced shivering was also attenuated in ORX-AB mice. Both mutants responded similarly to environmental heating (39°C). In WT and ORX-KO mice, the administration of PGE2 and cold exposure activated orexin neurons, as revealed by increased levels of expression of c-fos. Injection of retrograde tracer into the medullary raphe nucleus revealed direct and indirect projection from the orexin neurons, of which the latter seemed to be preserved in the ORX-AB mice. In addition, we found that glutamate receptor antagonists (D-(-)-2-amino-5-phosphonopentanoic acid and 6-cyano-7-nitroquinoxaline-2,3-dione) but not orexin receptor antagonists (SB334867 and OX2 29) successfully inhibited PGE2-induced fever in WT mice. These results suggest that orexin neurons are important in general thermogenic processes, and their importance is not restricted to stress-induced thermogenesis. In addition, these results indicate the possible involvement of glutamate in orexin neurons implicated in PGE2-induced fever.