[The Implication of Dietary Supplements and Herbal Medicines in Perioperative Period].

Total sales of dietary supplements and herbal medi- cines exceed two trillion yen in Japan. Approximately 60% of Japanese use dietary supplements or herbal medicines. In general, many people believe that dietary supple- ments and herbal medicines are safe natural prod- ucts; however, they could induce serious adverse events (bleeding, myocardial infarction stroke and glucose intolerance) in perioperative period. Coagulation and cardiovascular system can be nega- tively affected by those products. Thus careful preop- erative assessment is required for the patients who need regional anesthesia (e.g. epidural anesthesia and spinal anesthesia) and have cardiovascular complica- tions. Unfortunately there is no concise guideline regarding the use of supplements and herbal medicines during perioperative period. Anesthesiologists should be familiar with the adverse effects of dietary supplements and herbal medicines and pay more attention to non-prescribed medicines in preoperative assessment.

Feasibility, reliability, and validity of the Japanese version of the Postoperative Quality of Recovery Scale: a first pilot study.

The Postoperative Quality of Recovery Scale (PQRS) is a multi-domain tracking scale to assess recovery after surgery. The PQRS is used in seven countries and five languages; however, the Japanese version of the PQRS (PQRSj) has not been established. We therefore translated the PQRS into Japanese, and examined the feasibility, reliability and validity of the PQRSj. The time taken to complete the test was measured to assess feasibility. Cronbach's alpha was calculated to assess reliability. The Mini Mental State Examination (MMSE) and the Japanese version of the Quality of Recovery Scale 40 (QoR-40 J) were performed for comparison with the PQRSj (validity). Fifty-one patients were enrolled in the study. The mean completion time was 3.9 min for baseline (feasibility). Cronbach's alpha was between 0.40 and 0.94 in each domain (reliability). A relationship was shown between cognitive domain and MMSE at baseline (r = 0.65, P < 0.01); however, no relationship was found between the other domains and the MMSE and QoR-40 J. Ceiling effects were observed in 78% of the questions. These results indicate that the PQRSj can be used to assess recovery after surgery, although it may be better to revise some of the questions to improve the validity of the PQRSj.

Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia.

OBJECT: Recent evidence has indicated that the efficacy of the epidural blood patch (EBP) in the treatment of spontaneous CSF hypovolemia (SCH) is still limited. Therefore, further improvement of the EBP technique is an important clinical challenge. The authors describe a series of cases of SCH treated with fluoroscopically guided placement of an EBP and followed up with subsequent spinal CT scans. METHODS: Thirteen patients with SCH that was proven on CT myelography studies underwent epidural puncture under fluoroscopic guidance and received an injection of a mixture of contrast medium and autologous blood. Contrast medium was injected to cover the area of CSF leakage during EBP guided by fluoroscopy, and the spread of the blood was subsequently evaluated using spinal CT scanning. If the amount of blood injected was insufficient to cover the leakage area, a second EBP was performed at a later date. RESULTS: At the first EBP procedure, a mixture with a mean volume of 9.4 ml (range 3-20 ml) was injected, and subsequent spinal CT scans revealed contrast enhancement in the desired epidural space in 12 of 13 patients. In 2 patients, a second EBP was required because of insufficient coverage of the leakage area or delayed recurrence of headache. In all patients, a complete recovery from orthostatic headache was obtained after the last EBP. CONCLUSIONS: The results indicated that fluoroscopically guided EBP and subsequent spinal CT scans may provide a highly effective therapy in patients with SCH proven on CT myelography studies.

Effects of neuromuscular block on systemic and cerebral hemodynamics and bispectral index during moderate or deep sedation in critically ill patients.

OBJECTIVE: To investigate whether neuromuscular block can affect bispectral index (BIS) or cerebral hemodynamics under moderate or deep sedation produced by propofol. DESIGN AND SETTING: Prospective, controlled study in a university hospital affiliated intensive care unit. PATIENTS: Seventeen surgical patients undergoing elective esophagectomy. INTERVENTIONS: After stabilization with either light or deep sedation we investigated whether the BIS, electromyographic activity (EMG), or cerebral and systemic hemodynamic parameters were affected by administration of muscle relaxant. MEASUREMENTS AND MAIN RESULTS: Neuromuscular block reduced the BIS during moderate sedation but not during deep sedation although the EMG at both levels of sedation was significantly reduced. No positive effects of neuromuscular block on cerebral hemodynamics were obtained with monitoring of regional cerebral oxygen saturation and middle cerebral artery blood velocity; however, significant effects on systemic hemodynamic parameters were observed only at moderate propofol sedation. The values of BIS and systemic hemodynamic variables with moderate sedation were also very similar to those with deep sedation and neuromuscular block although these values differed without neuromuscular block. CONCLUSIONS: Neuromuscular block altered the BIS score in moderately sedated patients but not in deeply sedated patients although cerebral hemodynamics was not affected by neuromuscular block during either moderate or deep sedation. Muscular relaxant also enhanced cardiovascular stability with moderate sedation. These results suggest that level of consciousness may be decreased by neuromuscular block during moderate sedation but not affected during deep sedation.

Evaluation of relatively low dose of oral transmucosal ketamine premedication in children: a comparison with oral midazolam.

BACKGROUND: Oral Transmucosal ketamine (lollipop) has been shown to be an effective, harmless preoperative medication for children. However, its efficacy was not compared with commonly used premedication drugs. We, therefore, compared the efficacy of oral transmucosal ketamine with oral midazolam for premedication in children. METHODS: Fifty-five children (2-6 years of age) were randomized to receive orally either a lollipop containing 50 mg of ketamine (the group K; n = 27) or syrup containing 0.5 mg.kg(-1) of midazolam (the group M; n = 28) before minor surgery. A five points-sedation score (1 = asleep to 5 = agitated; scores 2 and 3 were defined as 'effective') on arrival in the operating room and a three points-acceptance score of separation from the parents and a three points-mask cooperation score at induction of anesthesia (1 = easy to 3 = markedly resistant; score 3 was defined as 'poor') were used. RESULTS: Sedation scores in group K were significantly higher than those in group M (P = 0.012), and the incidence of 'effective' in sedation was significantly lower in group K than in group M (P = 0.036). The incidence of 'poor' at separation from the parents and for mask cooperation was significantly higher in group K than in group M (P = 0.017, P = 0.019, respectively). CONCLUSION: These results indicate that a relatively low dose of oral transmucosal ketamine premedication provides no benefits over oral midazolam in children.

[Ilioinguinal/iliohypogastric nerve block for pediatric inguinal herniorrhaphy; evaluation of the dose of ropivacaine].

BACKGROUND: The aim of this study was to investigate the appropriate dose of ropivacaine in efficacy and safety when administered for ilioinguinal/iliohypogastric nerve block in children undergoing inguinal herniorrhaphy. METHODS: Forty six children (aged 1-8 yr, classified ASA I-II) undergoing ambulatory surgery for inguinal herniotomy were randomly assigned to one of the three groups, according to the dosage of ropivacaine: group I (n = 15), group II (n = 16) and III (n = 15) received 1.875, 0.9375 and 0.5625 mg x kg(-1) of ropivacaine, respectively. Intraoperative hemodynamics and modified CHEOPS score at 1, 3 and 5 hours after operation were recorded. RESULTS: There were no significant differences among the three groups in the intraoperative hemodynamics, whereas postoperative modified CHEOPS scores were significantly higher in group III than the other groups. Trivial femoral nerve palsy occurred in one patient of the group II, and no other adverse effects were seen in any groups. CONCLUSIONS: These results suggest that more than 0.9375 mg x kg(-1) of ropivacaine might be recommended to obtain sufficient postoperative analgesia for the ilioinguinal/iliohypogastric nerve block in children undergoing inguinal herniorrhaphy.

[Patient dissatisfaction with anesthetic care].

BACKGROUND: The evaluation of services by patients is an essential component of quality improvement in anesthesiology. Therefore, it is important to identify the factors for patient dissatisfaction. METHODS: We retrospectively studied 9974 consecutive patients who had received spinal or general anesthesia for elective surgery between 1999 and 2002. Pre-anesthetic, intra-anesthetic and post-anesthetic variables were recorded and patient satisfaction was assessed using direct interviews at the post-anesthetic clinic. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction. RESULTS: 348 of the 8843 respondents (3.9%) had dissatisfaction with anesthesia. The rates of dissatisfaction were higher in women than in men and in spinal anesthesia than in general anesthesia, and were observed mostly in the patients aged from 20 to 39 years. Qualitative data show that the common reasons for dissatisfaction with anesthesia were spinal anesthesia as the most dissatisfactory factor, followed by epidural anesthesia, postoperative pain, vomiting/nausea and memory of tracheal extubation. However, other various factors were associated with dissatisfaction. CONCLUSIONS: It is difficult for anesthesiologists to satisfy all patients, because patients' senses of values were varied. However, we conclude that anesthesiologists can improve the quality of anesthesia by enlightenment of the patient about anesthesia, and moreover, by better peri-anesthetic management for dissatisfactory factors with anesthesia.

[The effects of propofol on left ventricular systolic and diastolic function during induction of anesthesia--a transthoracic echocardiographic study].

BACKGROUND: The effects of clinical doses of propofol on left ventricular (LV) systolic function remain controversial and LV diastolic function has not been evaluated during induction of anesthesia with propofol. We assessed the effects of propofol on LV systolic and diastolic function during induction of anesthesia in adult patients with transthoracic echocardiography. METHODS: Twenty-three patients, ASA 1-2 and age < 70 y.o., received propofol 2 mg x kg(-1) for induction of anesthesia. LV systolic function was evaluated by fractional shortening (FS), ejection fraction (EF), rate-corrected mean velocity of circumferential fiber shortening (Vcfc) and a contractile index, LV end-systolic wall stress (ESWS) versus Vcfc relation (ESWS-Vcfc relation). LV diastolic functions were assessed by analysis of transmitral flow velocity, peak early diastolic and late diastolic filling velocities (E wave and A wave), E/A ratio and E wave deceleration time (DT). RESULTS: After induction, propofol preserved FS, EF, Vcfc and ESWS-Vcfc relation and caused a significant decrease in E wave and A wave, and a significant increase in E/A ratio and maintained DT. CONCLUSIONS: During induction of anesthesia in adult patients, propofol preserved LV systolic and diastolic functions.

[The effect of inhalation induction with sevoflurane on left ventricular systolic and diastolic function. A transthoracic echocardiographic study].

BACKGROUND: The effect of inhalation induction with sevoflurane on left ventricular(LV) function has not been evaluated in adults. We assessed the effect of inhalation induction with sevoflurane on left ventricular systolic and diastolic function in adult patients using transthoracic echocardiography. METHODS: Twenty-five patients (ASA 1-2 and age < 70 years) received inhalation induction with 5% of sevoflurane. LV systolic function was evaluated by fractional shortening (FS), ejection fraction (EF), rate-corrected mean velocity of circumferential fiber shortening (Vcfc) and a contractile index, LV end-systolic wall stress (ESWS) versus Vcfc relation (ESWS-Vcfc relation). LV diastolic function was assessed by analysis of transmitral flow velocity, peak early diastolic and late diastolic filling velocities (E wave and A wave), E/A ratio and E wave deceleration time (DT). RESULTS: After induction, sevoflurane caused significant decreases in FS, EF, Vcfc, ESWS-Vcfc relation, E wave, and A wave, and a significant increase in E/A and maintained DT. CONCLUSIONS: During inhalation induction with sevoflurane in adult patients, sevoflurane caused negative inotropic effects, but preserved LV diastolic function.

Intravenous administration of flurbiprofen does not affect cerebral blood flow velocity and cerebral oxygenation under isoflurane and propofol anesthesia.

UNLABELLED: Flurbiprofen, a nonsteroidal antiinflammatory drug (NSAID), has been used to treat rheumatic and osteoarthritic pain and to reduce postoperative pain. Although other NSAIDs, such as indomethacin, reduce cerebral blood flow (CBF), the effect of flurbiprofen on CBF is unknown. In the present study, we investigated the effects of flurbiprofen on cerebral blood flow velocity (CBFV) and cerebral oxygenation under isoflurane or propofol anesthesia. Forty-eight patients undergoing orthopedic or abdominal surgery were enrolled. Patients were randomly allocated to receive either propofol (target control infusion: target site effect concentration 3 microg/mL) or isoflurane (1 MAC) for maintenance of anesthesia. In each group (n = 12), 1 mg/kg of flurbiprofen (PROP-F and ISO-F groups) or 0.1 mL/kg saline (PROP-S and ISO-S groups) was administered i.v. for 5 min. During and after the administration of flurbiprofen or saline, cerebral oxygenation variables (tissue oxygen index [TOI], total hemoglobin change [Delta cHb], oxygenated hemoglobin changes [Delta O(2)Hb], and deoxygenated hemoglobin changes [Delta HHb]), and middle cerebral artery flow velocity (Vmca) were measured using a cerebral oximeter (NIRO 300) and transcranial Doppler, respectively, from 5 min before study drug administration to 60 min post-administration. Before the administration of flurbiprofen, control values of TOI in the ISO-S and ISO-F groups were significantly higher than those in the PROP-S and PROP-F groups, respectively (ISO-S versus PROP-S, 67% +/- 4% versus 60% +/- 7%; IOS-F versus PROP-F, 69% +/- 4% versus 63% +/- 8%; P < 0.05). However, values of TOI, Delta cHb, Delta O(2)Hb, Delta HHb, and Vmca did not change significantly during and after the administration of flurbiprofen under propofol or isoflurane anesthesia, and these values were similar to those during and after the administration of saline in the same anesthesia group. These data indicate that flurbiprofen does not affect CBFV and cerebral oxygenation under propofol or isoflurane anesthesia. IMPLICATIONS: Indomethacin, a nonsteroidal antiinflammatory drug (NSAID), has been demonstrated to reduce cerebral blood flow (CBF). The CBF effects of flurbiprofen, another NSAID, are unknown. We investigated cerebral blood flow velocity (CBFV) and cerebral oxygenation during and after the administration of flurbiprofen under isoflurane and propofol anesthesia. We found that flurbiprofen had no effect on CBFV and cerebral oxygenation.

[Anesthetic management of an infant with Freeman-Sheldon syndrome].

We report the anesthetic management of Freeman-Sheldon (whistling face) syndrome in a two-month-old boy scheduled for lateral canthoplasty. He had features of the syndrome including blepharophimosis, hypertelorism, a flat nose, microstomia with a limited opening, micrognathia, a very short webbed neck, scoliosis and multiple arthrogryposis. He was fed with a naso-gastric tube and suffered from several episodes of aspiration and oxygen desaturation. Difficult airway and intubation were anticipated. Anesthesia was induced via a mask with sevoflurane, although mask ventilation was difficult. Direct laryngoscopy and the insertion of a laryngeal mask airway were impossible due to microstomia with the limited opening as anticipated. A naso-tracheal intubation was achieved using a fiberoptic bronchoscope via a fiberoptic mask while ventilating the lungs. The operation and anesthesia afterwards were uneventful. In the ward, he was given supplemental oxygen but with occasional desaturation episodes. Thirteen days after the operation he was found cyanotic and resuscitation was attempted but failed. Autopsy demonstrated the hypoplasia of the lungs and thorax, atelectasis and bronchitis.