[A patient undergoing surgery for gastric cancer four weeks after insertion of a drug-eluting coronary stent].

We report a patient who underwent gastrectomy four weeks after a coronary stent insertion. A 79-year-old man suffering from unstable angina was transferred to our hospital and a sirolimus-eluting coronary stent was inserted into his right coronary artery. The day after receiving the coronary stent, the patient began vomitting bloody gastric fluid. Endoscopic findings showed Borrmann type 3 gastric cancer and a distal partial gastrectomy was scheduled four weeks after stent insertion. One week before the operation, the patient's aspirin and ticlopidine regimen was replaced with heparin injection, which was then discontinued twelve hours before the operation. After confirmation that his activated coagulation time was normalized, an epidural catheter was inserted and anesthesia was induced with midazolam 3.0 mg, fentanyl 0.1 mg and vecuronium 7.0 mg. Then propofol administration was began with a simulated blood concentration of 2 microg x ml(-1). Anesthesia was maintained using propofol infusions and intermittent epidural injections of local anesthetics. Hypotension was treated using an infusion of dopamine. The surgery was successfully performed and the patient was intensively monitored in the ICU. Heparin was restarted three days after the operation, and replaced with antiplatelet therapy five days after the operation. Six months after his gastrectomy, the patient underwent a right colon resection for invasive carcinoma. No complication, such as stent thrombosis or bleeding, occurred during the perioperative period.

[Epidural infusion of low dose bupivacaine after combined spinal-epidural anesthesia using needle through needle method provided no analgesic effect on postoperative pain after caesarian section].

BACKGROUND: In order to evaluate the analgesic efficacy of low dose epidural bupivacaine infusion with and without morphine after caesarean section we performed combined spinal-epidural anesthesia (CSEA) using needle through needle method. Three different epidural analgesic regimens were compared retrospectively. METHODS: The number of analgesic use during 24 hours after operation was compared. Patients were categorized into three groups; group N : intraoperative bolus epidural morphine (2.5 mg) alone, group L : bolus morphine (2.5 mg) plus epidural bupivacaine infusion (32 ml of 0.2% bupivacaine) at a rate of 2.1 ml x hr(-1), group M : bolus morphine (2.4 mg) plus epidural bupivacaine-morphine (33 ml of 0.2% bupivacaine containing morphine 2.3 mg) infusion at a rate of 2.1 ml x hr(-1). Used analgesics included pentazocine 15 mg i.m., diclofenac 25 mg suppo. and loxoprofen 60 mg p.o.. RESULTS: The mean number of analgesic use during the first 24 hours in group M (0.29 +/- 0.46) was significantly smaller than those of group N (0.97 +/- 0.91) and group L (0.84 +/- 0.95). Percentage of patients requiring no analgesic during the first 24 hours was significantly less in group M (70.8%) than in group N (33.4%) and group L (42.1%). CONCLUSIONS: A 2.1 ml x hr(-1) infusion of epidural bupivacaine has no analgesic effect after caesarean section under CSEA using NTN method.

Alteration of regional cerebral blood flow in patients with chronic pain--evaluation before and after epidural spinal cord stimulation.

BACKGROUND: Chronic pain is defined as intractable pain caused by abnormal pain transmission or impairment of the pain control system per se. Alteration of regional cerebral blood flow (rCBF) is known to occur under the presence of pain stimulation. Epidural spinal cord stimulation (SCS) is occasionally effective in relieving the symptom. OBJECTIVE: The aim of the current study is to investigate the alteration of rCBF in baseline condition and to find the association between the rCBF change and the efficacy of SCS in chronic pain. METHODS: A total of 18 patients underwent Tc-99m-HMPAO SPECT before and after SCS. Analysis with three-dimensional stereo-tactic surface projections (3D-SSP) with stereo-tactic extraction estimation (SEE) software was adopted to evaluate the rCBF. We assessed the extent score of the abnormal region in each segment (rate of the coordinates with a Z-value that exceeds three kinds of threshold value 2.0, 2.5 and 3.0 in all coordinates within a segment). According to the therapeutic response defined by visual analogue scale, we categorized patients into two groups, the good responder (GR) group (n=12) and poor responder (PR) group (n=6). In the analysis, we compared the extent score in the following two conditions. (1) Comparison between the PR group and normal control group under both baseline condition and after SCS. (2) Comparison between the GR group and normal control group under both baseline condition and after SCS. RESULTS: (1) In the PR group, increased rCBF was observed in left thalamus, bilateral precuneus and bilateral cerebellum under the baseline condition. After SCS, the range of these increased rCBF areas localized but remained. Decrease of rCBF was noted in bilateral subcallosal gyrus, superior temporal gyrus (STG) and bilateral anterior cingulate gyrus (ACG). They localized after SCS, but remained. (2) In the GR group, increased rCBF areas were noted in bilateral precuneus and bilateral cerebellum under the baseline condition. After SCS, they localized in bilateral precuneus but those of bilateral cerebellum remained. Decreased rCBF area was noted in bilateral subcallosal gyrus, STG and bilateral ACG under the baseline. After SCS, they localized in bilateral subcallosal gyrus and bilateral STG. In contrast, they enlarged in bilateral ACG. CONCLUSION: Chronic pain patients demonstrated abnormal rCBF distribution on both baseline and post SCS conditions. Increased rCBF of thalamus and precuneus under both conditions in the PR group and decreased rCBF of ACG under post SCS conditions in the GR group were characteristic patterns. Tc-99m-HMPAO SPECT with 3D-SSP and SEE analysis is likely objective and effective in monitoring and evaluating therapeutic outcome by SCS in chronic pain. In addition, it provides information that is useful in the selection of SCS candidates.

[A case of anaphylactic shock due to an antibiotic used preoperatively].

We report a case of an anaphylactic reaction due to a preoperatively administered antibiotic. A 72-year-old man scheduled to undergo cholecystectomy and choledocholithotomy received a cefoperazone infusion after being turned to a lateral position for insertion of an epidural catheter. Immediately after local injection of lidocaine, he, complained of inguinal itching. His systolic blood pressure then decreased to 60 mmHg and complained of discomfort and vomited. Soon, his systolic blood pressure decreased to 40 mmHg and he lost consciousness. Antibiotic infusion was stopped and he was returned to a prone, head-down position. His Spo2 decreased to 90%, and oxygen was administered. Following ephedrine 10 mg injection, his systolic blood pressure increased to 80 mmHg and he became conscious, but an erhythemic area appeared on his precordial region. Repeated epinephrine 0.05 mg injection restored his blood pressure to the preoperative level. Since a blood sample obtained 15 minutes after the event revealed high serum IgE levels, he was diagnosed as IgE-mediated anaphylactic reaction. Subsequent intradermal tests were tentatively positive to cefoperazone and negative to lidocaine. Surgery was successfully performed using cefotiam, which was also negative in a preoperative intradermal test.

Differential modulation by carbachol of four separate excitatory afferent systems to the rat subiculum in vitro.

The subiculum is a limbic cortical region that receives inputs from hippocampus and other parahippocampal regions. We used horizontal brain slices to study the modulatory effects of muscarinic receptor activation on excitatory afferent systems of the subiculum. Multiple inputs are preserved in these slices. Carbachol (CCh, applied to the bath) induced a decrease in the field responses (40-50% at 50 microM; 60% at 100 microM) to CA1, presubicular (PreS), and medial entorhinal (MEC) stimulation. Subicular responses to lateral entorhinal (LEC) stimuli were not depressed. The M1 receptor antagonist pirenzepine at 1 microM was sufficient to reverse most of the CCh-induced depression of afferent excitation, but 10 microM concentrations were required to eliminate the CCh-induced firing in the isolated subiculum. A partial reversal of the CCh-induced depression of afferent excitation was achieved by the M2 receptor antagonist methoctramine (1 or 10 microM), but these concentrations did not prevent CCh-induced firing. When CA1 afferents were repetitively activated with submaximal stimuli in the presence of CCh, population excitatory postsynaptic potentials (EPSPs) showed modest summation, but every response was smaller than a corresponding events in normal media. Population spikes, particularly late spikes in a train, showed pronounced facilitation during CCh exposure. The NMDA receptor antagonist CPP (10 microM) prevented facilitation of responses to repetitive stimulation in the presence of carbachol. We conclude that CA1, PreS, and MEC afferents to the subiculum exhibit CCh sensitivity similar to that established for area CA3 afferents to CA1, and LEC afferents to subiculum exhibit CCh resistance. Our data suggest that much of the hippocampal formation circuitry is modulated by CCh and the properties of this modulation can explain some specific firing characteristics of hippocampal formation neurons in "cholinergic" versus "noncholinergic" brain states.