Age-dependent decrease in desflurane concentration for maintaining bispectral index below 50.

BACKGROUND: We examined the hypothesis that the minimum alveolar concentration of desflurane for maintaining bispectral index (BIS) below 50 (MACBIS 50 ) decreases with advance of age. METHODS: Sixty young (20-30 year), middle-aged (31-65 year) and elderly (66-80 year) patients were included (n = 20, each group). Five minutes following the start of continuous intravenous administration of remifentanil at 0.25 µg/kg/min, general anaesthesia was induced with propofol 2 mg/kg and rocuronium 0.8 mg/kg to facilitate tracheal intubation. Infusion of remifentanil was stopped immediately after tracheal intubation. When BIS began to increase > 60, maintenance of anaesthesia was started with an end-tidal desflurane concentration of 4.0% and maintained for 10 min followed by 1-min assessment of BIS taken at 10-s intervals. MACBIS 50 of each age group was estimated by up-down methodology. RESULTS: MACBIS 50 of desflurane in young, middle-aged and elderly patients was 4.25% end-tidal (95% confidence intervals 4.04-4.46), 3.58% (3.38-3.79) and 2.75% (2.50-3.00) respectively. MACBIS 50 was higher (P = 0.011) in young patients and lower (P = 0.012) in elderly patients than those in middle-aged patients. CONCLUSIONS: Advance in age significantly decreased the concentrations of desflurane required to maintain BIS below 50. BIS reflected age-associated decrease in end-tidal concentrations of desflurane required for maintaining adequate depth of anaesthesia during resting state.

Spike-monitoring of anaesthesia for corpus callosotomy using bilateral bispectral index.

During corpus callosotomy for intractable epilepsy, the electrocorticogram is commonly recorded from electrodes placed on the brain surface to monitor of epileptic activity and assess the synchronisation of epileptic signals between the left and the right hemispheres. We evaluated the usefulness of bilateral bispectral index monitoring using two monitors and two sensors placed above the frontal region. Spikes were readily detected on the electroencephalogram on the bispectral index monitor, and the frequency of their occurrence increased or decreased in response to adjustment of the sevoflurane concentration. The disappearance of synchronisation between the left and the right hemispheres was observed with use of the bispectral index - in concordance with the electrocorticogram. Thus, 'spike-monitoring anaesthesia' using bilateral bispectral index was useful in assessing both the effect of anaesthetics on the electroencephalogram signals and the surgical therapeutic effect.

Effects of protein binding on the placental transfer of propofol in the human dually perfused cotyledon in vitro.

The placental transfer of propofol was investigated using the in vitro dually perfused cotyledon model of the human placenta, and the effects of protein binding in the foetal perfusate were examined. Both maternal and foetal circulations were perfused in a single-pass mode and > 30 min of stabilization was allowed before adding propofol and antipyrine to the maternal perfusate. The placental clearances of propofol were significantly increased by the augmented albumin concentrations in the foetal perfusate (1.68 (SD 0.68), 3.08 (1.55), 4.79 (1.76), 5.75 (1.89) and 7.03 (1.46) ml h-1 g-1 at the albumin concentrations of 4.4, 11, 22, 33 and 44 g litre-1, respectively). Although the total propofol concentration in the foetal vein increased significantly with increasing albumin concentration, the concentration of free propofol remained unchanged. These results indicate that binding to foetal albumin is a determining feature in the control of the placental transfer of propofol, and that the pharmacological effects of propofol on the foetus can be expected to be fairly constant and predictable from the maternal propofol concentration.

[Fluid management after off-pump CABG in a patient receiving preoperative continuous ambulatory peritoneal dialysis].

Perioperative management of off-pump CABG in a patient receiving continuous ambulatory peritoneal dialysis (CAPD) was reported. Prior to the procedure, we considered that postoperative management could be performed by CAPD alone in the case of off-pump CABG. However, due to an unexpected increase in the circulating blood volume and dilution of blood after surgery, congestive cardiac failure developed and active dehydration was required for 3 days after the operation using CHDF and HD. Despite this treatment, the central venous pressure and the cardiothoracic ratio in the chest X-ray were elevated, and a state of volume overload continued. However, cardiac contractility was not disturbed as shown by echocardiography. A possible cause of this condition was that body fluid had accumulated in the third space such as the peritoneum and intestine due to long-term use of CAPD before surgery, and the fluid was mobilized after surgery.

[Iatrogenic extrapleural hematoma].

We encountered a rare case of complications at the time of central venous catheterization due to extrapleural hematoma. A 71-year-old woman was scheduled to undergo subtotal gastrectomy. After introduction of general anesthesia, a CVP catheter was inserted from the right jugular vein, but it was removed intraoperatively, because of poor dropping of the infusion fluid. A few minutes later, the blood pressure started to decrease. We considered that this symptom was derived from the surgical procedure, and rapid blood transfusion associated with administration of a vasopressor was performed. Postoperative chest X ray revealed poorly delineated right lung field, and hemothorax was suspected. However thoracic drainage resulted in an extremely small amount of blood-like fluid. The abnormal defect in the right pulmonary field was found to be an extrapleural hematoma by thoracic CT on the first postoperative day. The hematoma was reduced by subsequent management in 7 days, and the patient was discharged from the ICU without any further complications.

Characterization of monoclonal antibodies to human protein 1/Clara cell 10 kilodalton protein.

Human protein 1/Clara cell Mr 10,000 protein consists of two identical subunits of seventy amino acid residues each. In the present study, eight clones of monoclonal antibodies against native protein 1 were prepared and their respective epitopes were immunochemically and immunohistochemically characterized using native protein 1, truncated recombinant protein 1 and synthesized peptides. Among the clones, three designated as TY-5, TY-7 and TY-8 recognized amino acid residues 7-16, residues 19-28, and residues 39-46, respectively, all of which comprise the hydrophobic cavity of protein 1, possibly associated with chemical binding function. With the exception of TY-4, the remaining clones recognized residues 61-68 which are exposed to solvent. The epitope of TY-4 remains undetermined. Proper selection and combination of clones and recombinant protein 1 may be useful for fundamental and clinical studies of protein 1.

[A successful cadaveric renal-transplantation in a patient whose serum inorganic fluoride concentrations were extremely elevated during sevoflurane anesthesia].

We gave general anesthesia using sevoflurane to a patient undergoing cadaveric renal transplantation. Although the maximum inorganic fluoride concentration in the serum was unexpectedly high (74 uM) in the perioperative period, urine output from the transplanted kidney started simultaneously with reperfusion of the kidney and renal functions also recovered swiftly. Enzyme induction caused by anticonvulsants, which had been administered prior to operation, was assumed to be the cause of the elevation in serum inorganic fluoride concentrations in the patient. We recognized that inorganic fluoride ion is not a primary factor to aggravate functions of the transplanted kidney and concluded that sevoflurane could be selected as a volatile anesthetic used in renal transplant surgery.

Improved oxygen delivery to the fetus during cesarean section under sevoflurane anesthesia with 100% oxygen.

PURPOSE: To assess the potential benefits of sevoflurane with 100% oxygen in cesarean section in terms of oxygen delivery to the fetus, neonatal depression, and uterine contractility. METHODS: Thirty-six patients undergoing elective cesarean section were enrolled. After thiamylal induction, 0.7% sevoflurane-60% nitrous oxide-40% oxygen anesthesia was administered in group G1 (n = 9), and 1.7% sevoflurane-100% oxygen anesthesia was administered in group G2 (n = 9). Spinal anesthesia under oxygen nasal prong was used in group SP (n = 18). RESULTS: At delivery, the PO(2) values in the maternal artery and the umbilical vein and artery (MA, UV, UA) of group G2 (474 +/- 50, 43 +/- 9, 32 +/- 9 mmHg, respectively) were significantly greater than those in groups G1 (228 +/- 46, 31 +/- 4, 23 +/- 5 mmHg, respectively) and SP (147 +/- 21, 30 +/- 7, 18 +/- 7 mmHg, respectively). The SO(2) in the UA of group G2 (56 +/- 17 %) was also greater than that in groups G1 (34 +/- 10 %) and SP (32 +/- 10 %). The sevoflurane concentrations at delivery in the MA, UV, and UA in group G2 were almost threefold higher than those in group G1, whereas all the newborns in the three groups had Apgar scores of 8 or more at 5 min, and the intraoperative blood loss did not differ among the groups. CONCLUSION: Sevoflurane anesthesia with 100% oxygen in elective cesarean delivery improves oxygen delivery to the fetus without severe neonatal depression, prolonged uterine relaxation, or increased blood loss.

[Unexpected anuria during Miles' operation in a renal-transplant patient].

We report a case of 33-yr-old-male after orthotopic renal transplantation 18 years ago, presenting with sudden anuria during Miles' operation. This anuria was caused by temporal compression of the transplanted kidney by retractor, neither by acute renal failure, the rejection nor the damage of the ureter by the surgical procedure. This case indicates that in the anesthetic management after renal transplantation, we have to be careful about renal dysfunction due to surgical procedure or positioning, in addition to side effects and pharmacokinetics of drugs used perioperatively.

[Is laparoscopic cholecystectomy minor invasive surgery?].

We conducted a comparative study to investigate whether or not laparoscopic cholecystectomy is less invasive and safer than abdominal subcostal laparotomy, using findings in blood pressure, heart rate, blood gas and endocrinological functions. In laparoscopic cholecystectomy, the patients' hospitalization period and expense for surgery were markedly reduced. However, those patients who underwent laparoscopic cholecystectomy had increases in blood pressure, heart rate, plasma cortisol and norepinephrine concentrations; it was assumed that these increases might be the result of reduced venous return to the heart which accompanied increased intra-thoracic and abdominal pressures, with reduction of cardiac output. In conclusion, since laparoscopic surgery is very advantageous for patients, we consider that for the success of this surgical procedure, it will be necessary to conduct safe anesthetic managements as well as to select patients carefully.

Immunohistochemical distribution of rabbit polyclonal antiurinary protein 1 antibody in the female (Skene's gland) and male prostate: new marker for neuroendocrine cells?

Using rabbit polyclonal antiurinary protein 1 antibody to study the female prostate (Skene's gland) and the male prostate, characteristic localizations patterns appeared in single cells and groups of cells. The majority correspond to cells positive for neuroendocrine markers. In the cytoplasm, cells positive for protein 1 were most frequently found in the epithelial lining of the female urethra, in the pars prostatica of the male urethra, and in the ducts of the female and male prostate where the lining consisted of pseudostratified columnar epithelium. Their occurrence rate was far lower among secretory and basal cells of the male and female prostate glands. The cells with protein 1 corresponded to those displaying positivity for chromogranin A, silver staining by the Grimelius and less by the Sevier-Munger method, and by neuron specific enolase. Using the Masson-Hamperl argentaffin method, positive cells were only exceptionally found. The cells positive for protein 1, and particularly chromogranin A, and characterized by Grimelius positivity, contained different amounts of neuroendocrine granules and varied in size and shape. The majority of these cells had contact with the lumen of male and female prostatic ducts (open type of neuroendocrine cells). In some cases of the male and female urethra and of the great paraurethral ducts, a remarkably high number of cells containing protein 1 corresponded to cells only containing neuron-specific enolase but not chromogranin A and other neuroendocrine markers. These cells can be considered stem cells responsible for the renewal of the uroepithelium of the urethra and prostatic ducts. Protein 1 may thus be a further, though presumably not specific marker for the identification of cells of the neuroendocrine system in the prostate of the male and female. This marker could well be used to study uroepithelium maturation. The corresponding immunohistochemical distribution of human protein 1 in neuroendocrine and other cells of the male and the female prostate provides another analogous functional and morphological parameter of prostatic tissue in both sexes and further evidence supporting the non-vestigial concept of the prostate in the female.

Serum and BAL Clara cell 10 kDa protein (CC10) levels and CC10-positive bronchiolar cells are decreased in smokers.

Cigarette smoking has diverse effects on the structure and function of the lung. Smoking appears to reduce the levels of Clara cell 10 kDa protein (CC10) in the alveolar lining fluid, but the influence of smoking serum on CC10 levels is still debated, and it has not been clear whether smoking reduces the number of CC10-producing lung cells. The aims of this study were to clarify the influence of smoking on CC10 levels in the alveolar lining fluid and bloodstream, and on the number of CC10-producing lung cells. CC10 concentrations were measured in sera and bronchoalveolar lavage (BAL) fluids, by means of enzyme-linked immunosorbent assay using monoclonal and polyclonal antibody, and the immunohistochemical expression of CC10 was examined in the lungs of nonsmokers and smokers using the monoclonal antibody, TY-5, against CC10/human urinary protein-1. CC10 concentrations in sera and in BAL fluids from healthy smokers were significantly lower than in healthy nonsmokers. Immunohistochemical expression of CC10 was found exclusively in nonciliated bronchiolar epithelial cells. As compared to that of nonsmokers, the mean percentage of CC10-positive bronchiolar epithelial cells was significantly decreased in lung tissue specimens obtained from smokers who had normal results in pulmonary function tests. It was concluded that smoking reduces the proportion of Clara cell 10 kDa protein-producing bronchiolar epithelial cells, resulting in decreased levels of Clara cell 10 kDa protein in the lower respiratory tract and in the bloodstream. The protein is a new blood biochemical and immunohistochemical marker, reflecting structural changes in peripheral airways induced by cigarette smoking.

Immunohistochemical localization of human protein 1 in the female prostate (Skene's gland) and the male prostate.

Mouse monoclonal anti-urine protein 1 antibody and the biotin-streptavidin-peroxidase technique were used for the immunohistochemical demonstration of human protein 1 in prostatic tissue of both sexes. In the female prostate (Skene's gland), like the male prostate, high expression of human protein 1 was observed on the luminal surface and in the apical cytoplasm of secretory cells of prostatic glands, as well as on the luminal surface of the epithelium of the large ducts of the female prostate and urethra. Expression was also found in the membranes of secretory and basal cells of the glands, in membranes of the urethral uroepithelium and of the female prostate ducts, in the content of glands and ducts, as well as in vascular endothelium and smooth muscle. Human protein 1 (urine protein 1) expression in the secretory cells of the male and female prostate and its incorporation into the surface of cells lining the lumina of the female urethroprostatic complex is indicative not only of the secretory role of protein 1 but also of its potential protective properties operative in shielding the uroepithelium from the aggressive urinary environment. All genito-urinary tissue, and especially the female prostate, were found to be a potential source of urine protein 1 (human protein 1), refuting the notion held so far that it is exclusively the genito-urinary prostatic tissue of the male that participates in its production. The corresponding immunohistochemical distribution of human protein 1 in the same structures of the male and female prostate provides yet another analogous functional-morphological parameter of prostatic tissue in both sexes and further evidence supporting the non-vestigial concept of the prostate in the female.

[Unexpected hydrothorax occurring after a long gynecological laparoscopic surgery--a case report].

We experienced a case of the hydrothorax occurring after a long gynecologic laparoscopical surgery. The patient was a 36-year-old woman, weighing 51 kg and 151 cm in height. She had received a gynecological laparoscopy with no complication 5 years before. She showed no abnormalities in the preoperative examinations. The operative course was uneventful. Upon completion of the surgery, we examined the chest X-ray, and found the hydrothorax in the right thoracic cavity. A 16 gauge Angiocath was inserted into the 4th intercostal space, and found 770 ml of fluid containing saline solution, which had been used for irrigating around the uterus. We presumed the saline, which was withdrawn from the right thoratic space, had originated from vertebrocostal trigone in the diaphragm. Because blood gas data were improving, the tracheal tube was extubated. We emphasise that the routine chest X-ray examination is necessary after pneumoperitoneum of long duration.

[Anesthetic management of a patient with esophageal hiatal hernia accompanied with chest pain].

We experienced the perioperative management of the esophageal hiatus hernia (sliding type). As the patient had had severe and frequent chest pain attacks and abnormal ECG, it was essential to evaluate the degree of cardiac and pulmonary functions. To prevent aspiration pneumonia, the patient had been placed on intravenous hyperalimentation and H2-blocker, and tracheal intubation was performed by rapid anesthetic induction technic without using awake or crash intubation methods. The intraoperative course was uneventful and the chest pain diminished immediately after the operation. In summary, the key points were as follows; (1) accurate evaluation of cardiac and pulmonary functions, and (2) prophylaxis for aspiration pneumonia at the time of anesthetic induction.

Preparation and characterization of human recombinant protein 1/Clara cell M(r) 10,000 protein.

Protein 1, which is identical to human Clara cell M(r) 10(4) protein, is a homodimeric, low molecular mass protein (M(r) 14,000) and an effective inhibitor of phospholipase A2 activity. We have expressed this protein in E. coli and characterized its physiochemical and biological properties. Using a pET expression system, about 1.7 mg of purified recombinant protein 1 was obtained from 250 ml of E. coli culture. The amino-terminal sequence of recombinant protein 1 up to the 20th residue was identical to that of native protein 1 except for an extra methionine at the amino-terminus. On reversed-phase HPLC, recombinant protein 1 eluted at the same retention time as native protein 1. The dose-response curves of recombinant protein 1 and native protein 1 in an enzyme-linked immunosorbent assay for protein 1 were identical. Recombinant protein 1 inhibited both porcine pancreas and cobra venom phospholipase A2 activities. These results indicated that recombinant protein 1 is structurally and biologically identical to native protein 1. We found that recombinant protein 1 also inhibits phosphatidylinositol-specific phospholipase C activity.