Anesthesia management for cesarean section in a woman with chronic renal failure and heart failure: a case report.

INTRODUCTION: Pregnancy in a woman with heart and chronic renal failure can lead to life-threatening complications for both mother and child. Although such cases are often delivered by cesarean section, few reports have described anesthesia methods. CASE PRESENTATION: We encountered a case in which cesarean section was performed using combined spinal and epidural anesthesia for a pregnant woman with chronic renal and heart failure. The 35-year-old Japanese woman had been undergoing hemodialysis for several years. Heart failure symptoms that appeared during pregnancy initially improved with treatments such as increasing hemodialysis, but recurred. She was admitted to the intensive care unit. The initial plan was to deliver the baby after a few weeks, but further progression of heart failure became a concern. After a clinical conference among staff, a cesarean section with combined spinal and epidural anesthesia was scheduled for 24 weeks, 0 days of gestation. The anticoagulant for dialysis was also changed from heparin to nafamostat in preparation for cesarean section. Monitoring was started with central venous and radial artery pressures before induction of anesthesia. Combined spinal and epidural anesthesia was induced and the cesarean section was completed without complications. Surgery was initiated under continuous administration of phenylephrine, which was intended to avoid hypotension due to anesthesia. The hemodynamic and respiratory status of the patient remained stable postoperatively. After the cesarean section, morphine was administered epidurally and the epidural catheter was removed. CONCLUSION: Cesarean section was safely performed for a pregnant woman with renal and heart failure using combined spinal and epidural anesthesia.

Education program for prevention of outdoor accidents in middle-high aged trekkers: Monitoring of change in blood pressure and heart rate during exercise.

This is an observational study to evaluate cardiovascular parameters during an educational trekking program. The number of alpine accidents involving elderly trekkers has been increasing in developed countries in recent years. Many middle-high aged trekkers have potential cardiovascular risks of which they are unaware. More than 77% of trekkers involved in alpine accidents in Japan were aged >40 years. The most common cardiovascular conditions were stroke or heart attack while trekking at altitude. An alpine club conducted an 8-month education program with participants aged >40 years in the setting of a mountain-side town. Blood pressure and heart rate during outdoor exercise were monitored, and any other adverse effects were recorded. As a result, the cardiovascular parameters evaluated during the first and final trek presented a physiological and similar behavior, however, lower heart rate values were registered at the highest point of the route in the final trek (p < 0.05). The trend of these parameters was similar in males and females, and there was little correlation between the cardiovascular parameters and age. In conclusion, the lower heart rate values may indicate the higher risk awareness of trekkers while self-pacing the physical activity outdoors, which may indicate the positive effect of the education program in increasing the safety of such unsupervised activities.

Comparison of four documents describing adrenaline purification, and the work of three important scientists, Keizo Uenaka, Nagai Nagayoshi and Jokichi Takamine.

The name of Keizo Uenaka has not been documented in textbooks. However, Uenaka was the scientist who worked on ephedrine and played a practical role in the purification and crystallization of adrenaline. His handwritten memorandum, "On Adrenaline, Memorandum, July to December, 1900" is now stored in a Buddhist temple, Kyougyou-ji in Nashio, Japan. In the present report, we compared Uenaka's original description and Jokichi Takamine's published scientific reports, and examined how each statement in four documents are related to each other in terms of successful adrenaline crystallization. Uenaka's memorandum contained precise procedures and experimental tips for successful purification. The experimental steps were considered to transcribed in the first published document in The American Journal of Pharmacy by Takamine in 1901, and summarized in another document in ``Journal of Physiology'' in 1901. A Japanese version was published in ``Yakugakuzasshi'' in 1903 by translating the English paper in the American Journal of Pharmacy published in 1901. Reading Uenaka's memorandum, we realized that he tirelessly and diligently undertook routine experiments that to some of us might seem boring and laborious. Although the name of Uenaka is not globally well known, he was the main scientist who did the actual work of purifying adrenaline.

Nonintubated video-assisted thoracoscopic surgery using adaptive servo ventilation in a patient with severe respiratory dysfunction: a case report.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is usually performed under general anesthesia with a double-lumen tube. Recently, VATS without tracheal intubation in a patient with severe respiratory dysfunction has been reported. A case of nonintubated (also known as awake or tubeless) VATS using adaptive servo ventilation (ASV), a form of noninvasive positive pressure ventilation providing varying amounts of ventilator support, is presented. This is the first report of nonintubated VATS using ASV. CASE PRESENTATION: A 60-year-old woman was scheduled for VATS bullectomy for the treatment of pneumothorax. She had severe respiratory dysfunction and had been receiving ASV therapy because of type 2 respiratory failure. Thus, nonintubated VATS using ASV, epidural anesthesia, and dexmedetomidine were selected. When surgical pneumothorax was created by incision of the pleura, her respiratory status remained stable. In addition, lung collapse was easily induced at operation. The leaking bulla was easy to identify, and bullectomy was performed. During surgery, she continued spontaneous breathing and did not complain of pain or discomfort. She was transferred to the intensive care unit with ASV and discharged on postoperative day 12 with no respiratory complications. CONCLUSION: It is necessary to maintain a stable respiratory status, as well as adequate analgesia and sedation, during nonintubated VATS in patients with severe respiratory dysfunction. When total lung collapse is not necessary for the surgical procedure, use of ASV would be an effective strategy.

The antihyperalgesic effects of intrathecal bupropion, a dopamine and noradrenaline reuptake inhibitor, in a rat model of neuropathic pain.

BACKGROUND: Antidepressants are often used for the treatment of neuropathic pain, and their analgesic effects rely on increased noradrenaline and serotonin levels in the spinal cord. Clinical studies have also shown that bupropion, a dopamine and noradrenaline reuptake inhibitor, has strong efficacy in neuropathic pain; however, the role of spinal cord dopamine in neuropathic pain is unknown. We hypothesized that bupropion inhibits neuropathic pain by increasing noradrenaline and dopamine in the spinal cord. In the present study, we determined the efficacy and underlying mechanisms of intrathecal administration of bupropion in a rat model of neuropathic pain. METHODS: Male Sprague-Dawley rats were anesthetized, and right L5 spinal nerve ligation (SNL) was performed to produce mechanical hyperalgesia of the hindpaw. Withdrawal threshold to a paw pressure test was measured before and after intrathecal administration of bupropion, without or with intrathecal antagonists for α2-adrenoceptors and dopamine D2 receptors. In vivo microdialysis was performed in the dorsal horn of the lumbar spinal cord to measure noradrenaline and dopamine concentrations after intrathecal injection of bupropion. We also measured the noradrenaline and dopamine contents in the ipsilateral dorsal lumbar spinal cord in normal rats and in rats 2, 3, and 4 weeks after SNL. RESULTS: Intrathecal injection of bupropion produced a dose-dependent antihyperalgesic effect (3, 10, 30, and 100 µg, P < 0.001). The effect (30 µg) was dose-dependently reversed by intrathecal pretreatment (15 minutes before bupropion injection) with the α2-adrenoceptor antagonist idazoxan (3, 10, and 30 µg, P < 0.001) and D2 receptor antagonist sulpiride (3, 10, and 30 µg, P < 0.001). Microdialysis revealed that noradrenaline and dopamine concentrations in the spinal dorsal horn were increased after intrathecal injection of bupropion (30 µg, P < 0.001 and P = 0.001, respectively). Furthermore, the noradrenaline and dopamine contents in the spinal dorsal horn were increased 2 weeks after SNL (P < 0.001 and P = 0.044, respectively) and then decreased gradually. CONCLUSIONS: These findings suggest that plasticity of descending inhibitory pathways such as the noradrenaline and dopamine systems contributes to the maintenance of neuropathic pain and that spinal cord noradrenaline and dopamine both play an inhibitory role in neuropathic pain.

CT-guided nerve block: a review of the features of CT fluoroscopic guidance for nerve blocks.

Nerve blocks are an attractive interventional therapy in pain medicine. Several image guidance methods are available to secure the safety, accuracy, and selectivity of the nerve block. Computed tomography (CT) guidance provides a clear view of the vital viscera and vessels that should be avoided by the needle, and accurate placement of the needle tip before neuro-destructive procedures. A recent advance in CT technology is multi-slice CT fluoroscopy, which allows for rapid and easy correction of needle tip placement during insertion. To reduce the radiation dose for both patients and staff, the lowest radiation setting, intermittent quick-check fluoroscopy, and shortening of the planning scan should be used. Preliminary CT scanning with excellent spatial resolution may facilitate the application of CT fluoroscopic guidance to various types of nerve blocks. Here we review celiac plexus and splanchnic nerve blocks, trigeminal nerve block, neurolytic sympathectomy, and spinal intervention performed under CT guidance. Additional large-scale studies are needed to optimize the use of image guidance, especially CT fluoroscopy guidance, for nerve blocks.

[Transient hyperglycemia following intra-peritoneal irrigation with 5% glucose in a patient with pseudomyxoma peritonei].

Pseudomyxoma peritonei is a condition characterized by the production of a large amount of mucopolysaccharide by a neoplastic epithelium. Although surgical removal of the mucinous ascites may be attempted, complete removal of the material is difficult. Thus, intra-peritoneal lavage with the liquid containing glucose or dextrose has been advocated to prevent reaccumulation of the mucus and complications such as bowel obstruction requiring repeated surgery. We report a case showing transient hyperglycemia following intra-peritoneal irrigation with 5% glucose in a patient with psudomyxoma peritonei. The patient was a 72-year-old woman. Preoperatively, she had hypertension and angina pectoris; but no history of glucose intolerance. Serum glucose was 92 mg x dl(-1). General anesthesia was induced with propofol (100 mg), vecuronium (6 mg), and fentanyl, and maintained with oxygen (33%), nitrous oxide and sevoflurane (1-2%). A mucinous tumor was found with a great deal of mucinous ascites. To remove the mucus and prevent subsequent re-accumulation, intra-peritoneal irrigation with 5% glucose in water was performed. Shortly after this procedure, the patient was found to be hyperglycemic (serum glucose 266 mg x dl(-1)) with normal oxygenation and hemodynamic data. The patient recovered uneventfully and could be extubated soon after surgery. Serum glucose level returned to 154 mg x dl(-1) one hour after surgery. Therefore, we think that this acute hyperglycemic condition, presumable due to intra-peritoneal irrigation, was transient. It is important to be aware of this dangerous complication associated with intra-peritoneal glucose instillation. Glucose monitoring during and after irrigation with glucose or dextrose is recommended.