Serial case report of high seizure threshold patients that responded to the lengthening of pulse width in ECT.

Electroconvulsive therapy (ECT) has been used as an effective treatment modality for psychiatric disorders. In patients with high seizure thresholds, augmentation strategies are considered such as changing anesthetic agents, hyperventilation, and premedication with theophylline. We tried to switch to "long (1.5 ms)" brief pulse ECT in all six patients from October 2020. The successful induction of effective seizures with "long" brief pulse stimulation in five of six patients who could not be treated adequately with standard ECT. In the current situation in cases in which brief pulse ECT, with the maximum dose did not lead to effective seizures, "long" brief pulse waves may be a promising option.

The effects of electroconvulsive therapy on tardive dystonia or dyskinesia induced by psychotropic medication: a retrospective study.

BACKGROUND: Tardive dystonia and dyskinesia are potentially irreversible neurological syndromes. Successful electroconvulsive treatment (ECT) has been reported by multiple sources; however, the existing retrospective reviews and open prospective trials provide little information on the response rate. METHODS: Eighteen consecutive patients with tardive dystonia or dyskinesia received a standard course of ECT to treat abnormal movement. The severity of the tardive dystonia and dyskinesia was evaluated using the Abnormal Involuntary Movement Scale (AIMS) before and after the course of ECT. The patients who displayed a greater than 50% improvement in the AIMS score were classified as the responders. RESULTS: The mean AIMS score decreased from 19.1±4.7 to 9.6±4.2. There were seven responders among the 18 patients, which yielded a 39% response rate. CONCLUSION: ECT has a moderate but significant effect on tardive dystonia and dyskinesia.

Identification of predictors of post-ictal delirium after electroconvulsive therapy.

AIM: Although electroconvulsive therapy (ECT) often causes post-ictal delirium (PID), to date, the specific risk factors of PID have not been described. The purpose of the present study was therefore to elucidate the predictors of PID via identification of the characteristics of patients with PID. METHODS: ECT was conducted in 50 patients and all patients underwent more than four sessions. A sine wave or a brief-pulse square wave ECT instrument was used. After convulsions the patients' PID was monitored for 30 min. The patients were allocated into four groups based on PID severity (none, mild, moderate or severe PID). Variables, including age, gender, duration of illness, diagnosis, clinical features (psychotic or catatonic features) and stimulus waveform (sine or brief pulse square waveform), were analyzed. RESULTS: Moderate to severe PID developed during the ECT sessions in 18 patients (36%). Most patients with severe delirium were successfully treated with i.v. bolus of propofol (1-2 mg/kg). Although the incidence of PID was 24% in patients without catatonic features, the incidence in patients with catatonic features was extremely high (88%; P < 0.001). Multiple regression analyses showed that the severity of PID correlated significantly with the presence of catatonic features (beta = 0.428, P < 0.01). CONCLUSION: The presence of catatonic features before ECT is a predictor of PID. Propofol is useful for the treatment of PID.

Bemegride lengthens seizure duration during electric convulsive therapy in a schizophrenic patient with increased seizure threshold.

A 48-year-old man who had a history of schizophrenia for 30 years was treated with electroconvulsive therapies. Because of poor seizure even at maximum electrical dosage, aminophylline was administered just before initiating electroconvulsive therapy. Although aminophylline augmentation lengthened the seizure duration, tachycardia and hypertension were observed. Therefore, we switched to bemegride, an antagonist to barbiturate, and seizure length was improved without any side effects. The present case suggested that bemegride is one of the alternative measures in patients with poor seizure quality.

Effective electroconvulsive therapy in a 92-year-old dementia patient with psychotic feature.

A 92-year-old woman who suffered from dementia with psychotic feature was admitted to a psychiatric ward. She refused to eat or take any medications. After 0.5 mg i.v. injection haloperidol, prolongation of QTc interval occurred in the electrocardiogram. Therefore two sessions of electroconvulsive therapy (ECT) were performed carefully after informed consent was obtained by her family. Almost no psychotic symptoms were observed after the first ECT. No cognitive side-effects were observed during and after the two ECT sessions. This demonstrates that ECT can be used as an alternative treatment when elderly dementia patients with psychotic feature cannot tolerate medication.

A history of aggression is a risk factor for postoperative confusion in elderly male drinkers.

PURPOSE: We investigated the relationship between preoperative psychological state and postoperative confusion in elderly drinkers. METHODS: We studied 81 male patients, ranging in age from 65 to 80 years, who were scheduled to undergo total hip arthroplasty and total knee arthroplasty. The patients were divided into two groups; non-drinkers and patients who drank 25 g or more of alcohol daily. All patients were given a neuropsychological screening evaluation, including a Mini-Mental State test, the Japanese version of the State-Trait Anxiety Inventory (STAI), a depression scale test, and evaluation of a history of aggression and postoperative confusion. RESULTS: Postoperative confusion during the first 72 h after the end of the operation occurred in 7 of the 50 non-drinkers (14%) and in 11 of the 31 drinkers (35%) (P = 0.01). There were no significant differences in STAI (state anxiety and trait anxiety), Mini-Mental State, and depression scale scores between the non-drinkers and drinkers, or between patients with and without postoperative confusion. All 8 patients who had a history of aggression developed postoperative confusion. There was no significant difference in the incidence of postoperative confusion between drinkers who did not have a history of aggression and non-drinkers. CONCLUSION: A history of aggression in elderly male drinkers is associated with postoperative confusion.

Postoperative interleukin-6 and cortisol concentrations in elderly patients with postoperative confusion.

OBJECTIVE: To investigate changes in plasma interleukin (IL)-6, cortisol or noradrenaline concentrations after surgery in elderly patients with postoperative confusion. METHODS: We studied 80 patients aged 70-90 years undergoing abdominal surgery and measured plasma IL-6, cortisol or noradrenaline concentrations before surgery, at the end of surgery, and 24 and 48 h after surgery. RESULTS: Plasma IL-6 concentrations in elderly patients with postoperative confusion were 83.2 +/- 30.5, 49.3 +/- 14.1 and 42.9 +/- 19.4 pg.ml(-1) at the end of surgery, and 24 and 48 h after surgery, respectively, being significantly higher than in elderly patients without postoperative confusion (58.0 +/- 37.5, 36.1 +/- 20.0 and 28.2 +/- 16.7 pg.ml(-1)). Plasma cortisol concentrations in elderly patients with postoperative confusion (42.2 +/- 7.8, 38.3 +/- 8.3 and 33.1 +/- 8.4 microg.dl(-1) at the end of surgery, and 24 and 48 h after surgery, respectively) were significantly higher than in elderly patients without postoperative confusion (32.9 +/- 6.7, 30.4 +/- 8.6 and 25.6 +/- 6.5 microg.dl(-1), respectively). There were no significant differences in plasma norepinephrine concentrations at all sampling points between elderly patients with and without postoperative confusion. However, plasma IL-6 and cortisol concentrations were related in elderly patients with postoperative confusion (at the end of surgery and 24 and 48 h after surgery). However, there was no relationship between plasma IL-6 and cortisol concentrations 24 and 48 h after surgery in elderly patients without postoperative confusion. CONCLUSION: Elderly patients with postoperative confusion had increased plasma IL-6 and cortisol concentrations. The interaction between IL-6 and cortisol after surgery is associated with developing postoperative confusion in the elderly patients.

Endocrine response to surgical stress and postoperative confusion in depressed patients with alcohol abuse.

Both alcohol drinking and depression are risk factors for postoperative confusion and are associated with alteration of pituitary-adrenal function. We investigated the incidence of postoperative confusion, plasma cortisol and ACTH response to surgical stress in depressed patients with alcohol abuse. We studied sixty depressed patients with and without alcohol abuse who underwent abdominal surgery. Postoperative confusion occurred in 4 of 30 patients (13%) in depressed patients without alcohol abuse, 10 of 30 patients (33%) in depressed patients with alcohol abuse. Plasma cortisol concentrations (27.2 +/- 7.0, 28.3 +/- 8.2, 29.2 +/- 4.1, 28.0 +/- 6.3 and 27.9 +/- 5.7 microg dl(-1)) 15, 60 min after the skin incision, 60 min after the end of surgery, the next day and the third day after surgery in depressed patients with alcohol abuse were significantly higher than that (20.1 +/- 6.4, 21.7 +/- 9.6, 22.3 +/- 8.0, 21.9 +/- 6.7 and 20.3 +/- 5.4 microg dl(-1)) in depressed patients without alcohol abuse. In depressed patients with alcohol abuse, plasma cortisol concentrations (34.9 +/- 7.1, 33.2 +/- 5.8 and 33.4 +/- 5.5 microg dl(-1)) 60 min after the end of surgery, the next day and third day after surgery in postoperatively confused depressed patients were significantly higher than those (26.4 +/- 6.3, 25.4 +/- 5.0 and 25.2 +/- 4.9 microg dl(-1)) of nonconfused depressed patients. In conclusion, the incidence of postoperative confusion was significantly higher in depressed patients with alcohol abuse than in depressed patients without alcohol abuse. Increased plasma cortisol concentrations after surgery were associated with postoperative confusion in depressed patients with alcohol abuse.

Increased cortisol response to surgery in patients with alcohol problems who developed postoperative confusion.

BACKGROUND: Patients with alcohol problems often develop postoperative confusion and have impaired cortisol, ACTH, and norepinephrine. However, the relationship between neuroendocrine responses to surgical stress and postoperative confusion remains unclear in patients with alcohol problems. METHODS: Plasma cortisol, ACTH, and norepinephrine concentrations during and after surgery in 30 patients with alcohol problems and 30 control patients who underwent lower abdominal surgery were measured before the induction of anesthesia, 15 and 60 min after skin incision, 60 min after the end of surgery, the next day, and the second day after the operation. RESULTS: Plasma cortisol concentrations (21.2 +/- 4.7 microg x dl) of patients with alcohol problems before anesthesia were significantly higher than 15.6 +/- 4.8 microg x dl(-1) of control patients. Plasma cortisol and ACTH responses to surgery in patients with alcohol problems were not significantly increased compared with preoperative values. The incidence of postoperative confusion was significantly higher in patients with alcohol problems than that of control patients (33% vs. 3%). Plasma cortisol concentrations (29.7 +/- 7.0, 31.2 +/- 6.6, 30.3 +/- 8.0, and 28.4 +/- 6.2 microg x dl(-1)) 15 and 60 min after the skin incision, 60 min after the end of surgery, and the next day after operation in postoperatively confused patients with alcohol problems were significantly higher than those of nonconfused patients with alcohol problems (23.0 +/- 5.8, 22.7 +/- 4.1, 22.4 +/- 7.2, and 21.9 +/- 5.5 microg x dl(-1)). CONCLUSION: The cortisol response to surgical stress increases in patients with alcohol problems who develop postoperative confusion, although cortisol response to surgical stress decreases in patients with alcohol problems without postoperative confusion.

Postoperative confusion in schizophrenic patients is affected by interleukin-6.

STUDY OBJECTIVE: To investigate whether epidural analgesia with local anesthetics affects postoperative confusion in schizophrenic patients or the relationships between cortisol or interleukin-6 (IL-6) and postoperative confusion. DESIGN: Prospective, randomized study. SETTING: Hakodate Watanabe Hospital and Hirosaki National Hospital. PATIENTS: 105 patients who were scheduled to undergo abdominal surgery with general anesthesia. INTERVENTIONS: The schizophrenic patients were rendomly divided into two groups: patients in Group A received epidural anesthesia and patients in Group B did not receive epidural anesthesia. MEASUREMENTS AND MAIN RESULTS: Postoperative confusion during the first 48 hours after the end of operation occurred in 7 of 33 patients (21%) in Group A and 10 of 33 patients (30%) in Group B. There were no significant differences in the frequency of postoperative confusion between Groups A and B. Plasma cortisol concentrations in schizophrenic patients in Group A were significantly lower 15 minutes after incision and the end of surgery than those levels of patients in Group B; however, there was no significant difference between groups in plasma cortisol concentrations after anesthesia. Plasma IL-6 concentrations (51.7 +/- 22.0 and 31.4 +/- 8.2 pg mL(-1)) in patients with postoperative confusion at the end of surgery and 24 hours after surgery were significantly higher than those levels (34.4 +/- 16.2 and 16.9 +/- 7.7 pg mL(-1)) in patients without postoperative confusion. CONCLUSIONS: Epidural anesthesia does not significantly decrease the frequency of postoperative confusion in schizophrenic patients. Plasma IL-6 concentrations at the end of the operation and 24 hours after surgery in schizophrenic patients with postoperative confusion were significantly higher than those concentrations in patients without postoperative confusion.

Norepinephrine-induced inositol 1,4,5-trisphosphate formation in atrial myocytes is regulated by extracellular calcium, protein kinase C, and calmodulin.

We investigated whether alteration of extracellular and intracellular Ca2+ concentrations, protein kinase C, and calmodulin modulate norepinephrine (NE)-induced inositol 1,4,5-trisphosphate (IP3) formation in neonatal rat atrial myocytes. NE-induced IP3 production in atrial myocytes was stimulated by elevation of extracellular Ca2+ in a dose-dependent manner. However, TMB-8 (an intracellular calcium antagonist) and A23187 (an intracellular calcium agonist) did not significantly affect NE-induced IP3 production. PMA (a protein kinase C agonist) significantly decreased and staurosporine (a protein kinase C antagonist) significantly stimulated NE-induced IP3 production. W7 (a calmodulin antagonist) significantly increased the NE-induced IP3. In conclusion, elevation of extracellular Ca2+ concentrations affects NE-induced IP3 formation in atrial myocytes. Protein kinase C and calmodulin may control the IP3 response to NE by a negative feedback mechanism.

Ketamine inhibits endotoxin-induced inositol 1,4,5-triphosphate in rat ventricular cardiomyocytes.

OBJECTIVE: To investigate the effect of ketamine on endotoxin modulation of inositol 1,4,5-triphosphate (IP3) formation in cardiomyocytes. DESIGN: A prospective observational cell culture study. SETTING: A research laboratory in the University of Hirosaki School of Medicine. MATERIALS: Neonatal rat cardiomyocytes. INTERVENTION: We investigated bradykinin-induced IP3 production in the presence of lipopolysaccharide (LPS) and the effect of ketamine on the LPS modulation of IP3 formation. The LPS modulation of IP3 formation was measured in the presence of BM13177 (a thromboxane A2 (TXA2) receptor inhibitor) or GDPbetaS (a GTP-binding protein inhibitor). U46619 (a TXA2 agonist)-induced IP3 production was measured in the presence of ketamine, and the ketamine modulation of U46619-induced IP3 production was measured in the presence of W7 (a Ca2+ releasing agent) and verapamil (a Ca2+ channel blocker). RESULTS: One micromole ketamine significantly attenuated the LPS-induced IP3 production from 763.8+/-34.6 to 461.6+/-65.1 pmol mg protein(-1). Ten micromoles of BM13177 or 1 mM GDPbetaS significantly blocked LPS modulation of bradykinin-induced IP3 production from 786.0+/-33.8 to 218.6+/-21.6 and 226.8+/-25.4 pmol mg protein(-1). One micromole of ketamine significantly decreased U46619-induced IP3 production from 857.3+/-45.0 to 632.9+/-64.5 pmol mg(-1) protein. The ketamine inhibition of U46619-induced IP3 production was enhanced by W7 and inhibited by verapamil. CONCLUSION: Ketamine decreased LPS-induced IP3 formation and the ketamine inhibition was associated with inhibition of the TXA2-IP3 sequence. Inhibition of TXA2 by ketamine was associated with a decrease in intracellular Ca2+.

Increased postoperative pain scores in chronic depression patients who take antidepressants.

STUDY OBJECTIVE: To investigate postoperative pain and current perception thresholds in chronic depression in patients who are treated with antidepressants. DESIGN: Prospective, randomized study. SETTING: Hakodate Watanabe Hospital and Hirosaki National Hospital. PATIENTS: 30 patients with major depression and 30 control patients who underwent abdominal surgery with general anesthesia. INTERVENTIONS: Postoperative pain scores via visual analog scale (0-100), current perception thresholds at 5, 250, and 2000 Hz. MEASUREMENTS AND MAIN RESULTS: Postoperative pain scores of depressed patients at 8 and 16 hours after the end of anesthesia were 36.2 +/- 10.4 and 33.4 +/- 8.5, which were significantly higher than 25.2 +/- 9.3 and 22.7 +/- 8.5 scores of the control patients. Current perception thresholds at 5 Hz, 250 Hz, and 2000 Hz in depressed patients were 38.2 +/- 6.7, 76.1 +/- 11.3, and 190.8 +/- 19.2, respectively. There were no significant differences between the depressed patients and control patients in current perception thresholds at 5 Hz, 250 Hz, and 2000 Hz. We found that visual analog scale scores in depressed patients at 8 and 16 hours after the end of anesthesia correlated with the Hamilton Depression Scale scores before operation. CONCLUSIONS: The degree of postoperative pain in depressed patients who take antidepressants depends on their depressive state.

Schizophrenic patients who develop postoperative confusion have an increased norepinephrine and cortisol response to surgery.

The purpose of this study was to investigate the relationship between postoperative confusion and the plasma norepinephrine (NE), adrenocorticotropin (ACTH) or cortisol response to surgery in schizophrenic patients. We studied 50 schizophrenic patients and 35 control patients who underwent orthopedic surgery and perioperatively measured plasma NE, ACTH and cortisol levels. Postoperative confusion during 72 h after the end of the operation occurred in 14 of 50 schizophrenic patients (28%) and in 2 of 35 control patients (6%). Plasma NE levels 15 min after skin incision, the next day, the second day and the third day after operation in schizophrenic patients with postoperative confusion (668.0 +/- 59.2, 522.0 +/- 96.5, 463.2 +/- 71.2 and 398.9 +/- 56.2 pg/ml, respectively) were significantly higher than those in schizophrenic patients without confusion (524.1 +/- 62.6, 342.4 +/- 38.6, 311.2 +/- 58.3 and 314.1 +/- 77.1 pg/ml, respectively). Plasma cortisol levels 15 min after the skin incision and the next and second days after operation in schizophrenic patients with postoperative confusion (23.6 +/- 3.2, 21.1 +/- 4.3 and 19.9 +/- 4.4 microg/dl, respectively) were significantly higher than those in schizophrenic patients without confusion (15.2 +/- 4.5, 14.3 +/- 5.1 and 13.8 +/- 3.8 microg/dl, respectively). In conclusion, the occurrence of postoperative confusion in schizophrenic patients is associated with an increase in plasma norepinephrine and cortisol levels during and after surgery.

Cortisol response to surgery and postoperative confusion in depressed patients under general anesthesia with fentanyl.

The purpose of this study was to investigate the relationship between postoperative confusion and plasma cortisol response to surgery in depressed patients. We studied 80 depressed patients and 40 control patients who had undergone orthopedic surgery and perioperatively measured plasma cortisol and adrenocorticotropin levels. Postoperative confusion in the first 3 postoperative days occurred in 5 (13%) depressed patients given fentanyl during anesthesia, 13 (33%) patients without fentanyl and 1 (3%) control patients. Plasma cortisol concentration (19.7 +/- 6.9 and 19.2 +/- 8.0 microg dl(-1)) 15 min after skin incision and 60 min after the end of surgery in depressed patients with fentanyl was significantly lower than that (24.2 +/- 7.2 and 23.5 +/- 8.1 microg dl(-1)) of depressed patients without fentanyl. Plasma cortisol levels during and after surgery in depressed patients with postoperative confusion were higher than those of depressed patients without postoperative confusion. We conclude that the occurrence of postoperative confusion in depressed patients is associated with an increase in plasma cortisol levels during and after surgery. The incidence of postoperative confusion in depressed patients with fentanyl was significantly lower than that of depressed patients without fentanyl.

Atrial natriuretic peptide increases glucose uptake during hypoxia in cardiomyocytes.

The action of atrial natriuretic peptide on glucose uptake during hypoxia was investigated in neonatal cardiomyocytes. When the cultures were exposed to 100 n and 1 and 10 micro M of atrial natriuretic peptide for 60 min, hypoxia-induced glucose uptake significantly increased from 20.4 +/- 1.2 to 28.2 +/- 3.1, 31.6 +/- 2.7, and 30.1 +/- 2.8 pmol/h/mg protein, respectively, although atrial natriuretic peptide alone did not significantly affect the basal glucose uptake in normoxic condition. The atrial natriuretic peptide-stimulated glucose uptake during hypoxia was significantly decreased by 100 n of genistein and tyrphostin A-23 (a tyrosine kinase inhibitor) from 31.6 +/- 2.7 to 22.8 +/- 2.4 and 23.8 +/- 2.7 pmol/h/mg protein. U73122 100 n, which is a phospholipase C antagonist, significantly inhibited the atrial natriuretic peptide-induced glucose uptake under hypoxic conditions from 31.6 +/- 2.7 to 13.6 +/- 1.9 pmol/h/mg protein. However, the atrial natriuretic peptide-induced glucose uptake did not involve elevation of intracellular Ca and phosphatidylinositol (PI)3 kinase. It was concluded that the atrial natriuretic peptide-stimulated glucose uptake during hypoxia acts through a phospholipase C-tyrosine kinase pathway.

Small-dose ketamine improves the postoperative state of depressed patients.

UNLABELLED: We investigated whether ketamine is suitable for depressed patients who had undergone orthopedic surgery. We studied 70 patients with major depression and 25 patients as the control (Group C). The depressed patients were divided randomly into two groups; patients in Group A (n = 35) were induced with propofol, fentanyl, and ketamine and patients in Group B (n = 35) were induced with propofol and fentanyl, and all patients were maintained with 1.5%-2.0% isoflurane plus nitrous oxide. The mean Hamilton Depression Rating (HDR) score was 12.7 +/- 5.4 for Group A and 12.3 +/- 6.0 for Group B 2 days before surgery and 9.9 +/- 4.1 for Group A and 14.4 +/- 3.8 for Group B 1 day after surgery. The HDR score in Group A 1 day after surgery was significantly (P < 0.05) lower than that in Group B. The HDR score in Group C was 4.2 +/- 1.7 2 days before surgery and 4.8 +/- 1.6 1 day after surgery. Depressed mood, suicidal tendencies, somatic anxiety, and hypochondriasis significantly decreased in Group A as compared with Group B. Postoperative pain scores in Group A at 8 and 16 h after the end of anesthesia were 26.6 +/- 8.7 and 24.9 +/- 8.2, respectively, which were significantly (P < 0.05) lower than 34.3 +/- 12.0 and 31.1 +/- 8.8 in Group B. In conclusion, small-dose ketamine improved the postoperative depressive state and relieved postoperative pain in depressed patients. IMPLICATIONS: NMDA receptor antagonists are reported to be effective for improving depression. It remains unclear whether ketamine, which is an NMDA receptor antagonist, postoperatively affects the psychological state in depressed patients. We investigated the effect of 1.0 mg/kg of ketamine on postoperative outcomes in depressed patients.

Sevoflurane increases glucose transport in skeletal muscle cells.

UNLABELLED: Sevoflurane activates phospholipase C and protein kinase C, leading to an increase in intracellular Ca(2+) concentration, which modulates glucose transport. We studied in vitro the effect of sevoflurane on the uptake of 2-deoxyglucose in rat skeletal muscle cells and the mechanism that modulates the glucose transport. Sevoflurane 0.8, 1.2, and 2.0 mM significantly increased glucose uptake from 13.1 +/- 1.2 pmol. h(-1). mg protein(-1) to 22.6 +/- 1.4, 32.1 +/- 1.8, and 37.4 +/-2.7 pmol. h(-1). mg protein(-1), respectively. Tyrphostin A-23 (a highly selective tyrosine kinase inhibitor) 1 and 10 nM significantly decreased the sevoflurane-stimulated glucose uptake from 32.1 +/- 1.8 to 25.8 +/- 1.1 and 15.2 +/- 1.7 pmol. h(-1). mg protein(-1), respectively. Genistein (a selective tyrosine kinase inhibitor) 1 and 10 nM also significantly decreased the sevoflurane- stimulated glucose uptake from 32.1 +/- 1.8 to 25.7 +/- 1.5 and 15.2 +/- 1.4 pmol. h(-1). mg protein(-1), respectively. The sevoflurane-stimulated glucose uptake was decreased by 100 nM and 1 microM TMB-8 (an intracellular Ca(2+) antagonist), from 32.1 +/- 1.8 pmol. h(-1). mg protein(-1) to 25.6 +/- 3.3 and 20.3 +/- 1.6 pmol. h(-1). mg protein(-1), respectively. Staurosporine (a protein kinase C antagonist) 100 nM significantly decreased sevoflurane-stimulated glucose uptake to 26.1 +/- 1.5 pmol. h(-1). mg protein(-1). We conclude that sevoflurane increases glucose uptake in skeletal muscle cells and that the sevoflurane-stimulated glucose uptake was associated with tyrosine kinase, protein kinase C, and intracellular Ca(2+). IMPLICATIONS: Sevoflurane anesthesia has an inhibitory effect on insulin secretion. Glucose concentrations in plasma do not significantly change during sevoflurane anesthesia. Plasma glucose concentrations are affected by intracellular glucose metabolism. However, glucose transport into cells during sevoflurane anesthesia remains unclear.

[A successfully treated case of aspiration pneumonia with adult respiratory distress syndrome and shock].

Right hip replacement was scheduled for a 74-year-old man who was treated with morphine for cancer pain. As the patient developed dyspnea and hypoxia after anesthesia, he was intubated and kept under mechanical ventilation. A diagnosis of aspiration pneumonia with adult respiratory distress syndrome was made based on the detection of gall obtained from the endotracheal tube. A chest X-ray showed pulmonary edema. He was treated with positive pressure ventilation and inotropic support. As he developed severe shock 10 hours after the intubation, he was treated with 20 mg.kg-1 of methylprednisolone for 3 days. The steroid therapy was successful and he was extubated on the 6th postoperative day and was discharged from the ICU on the 7th postoperative day. High-dose pulse methylprednisolone therapy resulted in a remarkable clinical improvement. Corticosteroids rescue treatment is effective for such a severe case of aspiration pneumonia with shock when the treatment is done in the early phase of the pneumonia.

Anesthesia with ketamine, propofol, and fentanyl decreases the frequency of postoperative psychosis emergence and confusion in schizophrenic patients.

STUDY OBJECTIVE: To investigate whether total IV anesthesia with ketamine, propofol, and fentanyl affects the frequency of postoperative psychosis emergence or confusion in schizophrenic patients. DESIGN: Prospective, controlled study. SETTING: Hirosaki National Hospital and Hakodate Watanabe Hospital. PATIENTS: 76 ASA physical status I and II schizophrenic patients taking chronic antipsychotic drugs and schedule for orthopedic surgery of extremities. INTERVENTIONS: In Group A (n = 38) patients, anesthesia was maintained with sevoflurane, nitrous oxide, and fentanyl. In Group B (n = 38) patients, anesthesia was maintained with ketamine, propofol, and fentanyl. MEASUREMENTS AND MAIN RESULTS: The frequency of psychosis emergence or confusion (54%) in Group A during the first 48 hours after surgery was significantly higher than the 30% figure in Group B. CONCLUSION: Ketamine, when combined with propofol and fentanyl, is an appropriate anesthetic drug for schizophrenic patients.