Effectiveness of Respite Care via Short-Stay Services to Support Sleep in Family Caregivers.

Family caregivers of older people who need care often experience sleep disorders, which can lead to various health problems. Although respite care is used in many countries, its effectiveness has not been fully demonstrated. We analyzed the sleep of family caregivers using actigraphy and heart rate spectral analysis to clarify changes in their sleep characteristics during short-stay respite care. Participants were all family caregivers living with an older person needing long-term care. The outcomes consisted of questionnaire responses, sleep/wake records, and R-wave to R-wave interval records. Quantitative evaluation of sleep revealed that caregivers' median sleep time was 378.0 min, and median sleep efficiency was 94.7%. The low frequency (LF)/high frequency (HF) value was 1.722 for total sleep and 1.822 for the first half of the sleep period. The LF/HF for the first half of the sleep period was significantly different between caregiving and respite days. The respite day LF/HF was 1.567, which was significantly lower than on caregiving days. On respite days, cardiac sympathetic nervous activity among family caregivers was reduced during the first half of the sleep period. This suggests that regular use of short-stay services can improve caregivers' sleep status, making this an effective form of respite care.

[A Case of Suspected Delayed Postoperative Malignant Hyperthermia].

Malignant hyperthermia occurred 10 hours after surgery in a 72-year-old man who had received emergency laparoscopic cholecystectomy for severe acute cholecystitis with cholelethiasis. He had a high fever (39.4 degrees C) with liver damage before surgery. Anesthesia was induced with propofol and fentanyl and maintained with sevoflurane and epidural block using ropivacaine. Rocuronium was used as a muscle relaxant During surgery, body temperature decreased by cooling the body surface, but tachycardia continued. Ten hours after surgery, body temperature increased to the maximum of 40.6 degrees C and he went into shock. Then another 10 hours later, he developed cardiac arrest He recovered, but 22 hours later, second cardiac arrest occurred. After his second recovery, dantrolene was administered and body temperature decreased. He had hypoxic brain damage, but was dischanged from the hospital after tracheostomy on the 150th hospital day. From his clinical course, especially decrease in body temperature by dantrolene, he was suspected to have developed malignant hyperthermia. We should consider malignant hyperthermia when patient had a severe high fever postoperatively.

[A case report of ultrasound guided peripheral nerve block for lower extremity amputation of a patient with anti-phospholipid syndrome].

A 60-year-old female with anti-phospholipid syndrome underwent amputation of her left lower limb. She had had a history of cerebral infarction, cerebral hemorrhage, coagulation abnormalities, thrombocytopenia, and pneumothorax, and just recovered from disseminated intravascular coagulation. After intravenous fentanyl 25 microg, ultrasound-guided sciatic, femoral and lateral femoral cutaneous nerve blocks were performed. We used 0.75% ropivacaine 15 ml and 1% lidocaine 15 ml for sciatic nerve block, 0.75% ropivacaine 5 ml and 1% lidocaine 5 ml for femoral nerve block and 0.75% ropivacaine 5 ml for femoral cutaneous nerve block. For femoral nerve block, a catheter was inserted and ropivacaine was infused at 4 ml x hr(-1) after surgery. Amputation at the left thigh was successfully performed and postoperative course was uneventful. The sciatic, femoral and lateral femoral cutaneous nerve blocks were useful for amputation of a patient with severe coagulopathy by anti-phospholipid syndrome.

[A case of prolonged hypercapnea after interscalene brachial plexus block].

An 83-year-old woman was scheduled for surgery of the left upper and lower extremity fracture. She had past history of lung partial resection for lung cancer and rheumatoid arthritis, and recent history of pneumonia. She also had fluid retention in the thoracic cavity. Open resection of the femoral neck fracture was first performed uneventfully under spinal anesthesia with bupivacaine 0.5% 2 ml. Then, interscalene blaxioplexus block was performed with 0.75% ropivacaine 15 ml and 1% lidocaine 10 ml for tension band wiring of the fractured olecranon. Midazolam 1 mg and propofol 1.5 mg x kg(-1) x hr(-1) were administered for sedation. Thirty minutes after the block, oxgen saturation decreased to 92% under O2 3 l x min(-1) by a mask. She was intubated and arterial carbon dioxide tension was above 150 mmHg. A few hours later, she became conscious and mask CPAP was used after extubation for one day. Pa(CO2) was 90-100 mmHg for 3 days and decreased to 56.9 mmHg on the 6th day, but her consciousness had been clear. Phrenic nerve palsy and sedation in the patient with decreased lung function might have induced prolonged hypercapnea.

[Anesthesia for open reduction of ankle fracture in a patient with giant pituitary adenoma].

A few cases of the pituitary apoplexy have been reported after spinal anesthesia in patients with pituitary tumor. A patient with giant pituitary adenoma underwent open reduction of the ankle fracture. This 69-year-old man had no symptoms related to pituitary adenoma. Femoral and sciatic nerve blocks were chosen to avoid pituitary apoplexy, cerebral herniation and other complications related to spinal anesthesia. The surgery was successfully done without any complications and the patient was discharged uneventfully 25 days after surgery. When patient has a giant pituitary tumor, peripheral nerve block might be a good choice for anesthesia.

[Repeated anesthesia for a patient with Tako-Tsubo cardiomyopathy].

An 85-year-old woman recieved emergency repair of left obturator hernia under general anesthesia. The surgery was completed uneventfully. Shortly after the admission to the recovery unit, blood pressure dropped to 80mmHg and ECG showed negative T wave. Hypotension was successfully treated with colloid infusion and dopamine administration, but negative T wave was unchanged by nitrate infusion. The serum CK-MB examination indicated no cardiomyogenic problems. On postoperative day 13, she received emergency colostomy under general anesthesia. Large negative T wave still persisted. Immediately after induction of anesthesia, she showed hypotension, which recovered by fluid infusion and intravenous ephedrine. The UCG after surgery showed hypokinesis of the apex of left ventricle. She was diagnosed as Tako-tsubo myocardiopathy. One month after the second surgery, she received closure of colostomy under general anesthesia combined with continuous epidural anesthesia, when negative T wave was seen on the ECG. Negative T wave returned to normal 10 weeks after the first surgery. When unknown tachycardia and negative T waves are seen, Tako-tsubo cardiomyopathy should be considered.

The effects of prewarming the I-gel on fitting to laryngeal structure.

PURPOSE: The supraglottic airway, I-gel (Intersurgical, Wokingham, United Kingdom), has a noninflatable cuff, which softens at body temperature to fit to laryngeal structure. The present study was performed to investigate the hypothesis that the cuff of I-gel can fit to laryngeal structure faster when prewarmed to body temperature than kept at room temperature. METHODS: A total of 180 adult patients were assigned to the warm group (90 patients) or the control group (90 patients). Anesthesia was induced with propofol, remifentanil, or fentanyl. Vecuronium or rocuronium was administered as a muscle relaxant. The I-gel was warmed to 37 °C before insertion in the warm group and it was in the room temperature (approximately 20 °C) in the control group. Insertion time, number of attempt for successful insertion, inspiratory pressure, leak pressure, and leak volume were compared between the 2 groups. RESULTS: Insertion time was 12.9 ± 9.3 seconds in the warm group and 14.5 ± 12.3 seconds in the control group. Number of attempt for insertion was 1 in 77 cases, 2 in 4 cases, and 3 in 1 case in the warm group and 1 in 79 cases and 2 in 7 cases in the control group. Inspiratory pressure, leak pressure, and leak volume were not significantly different between the 2 groups, whereas leak volume had a tendency to be smaller in the warm group. CONCLUSION: Prewarming the I-gel to body temperature did not have any significant benefits in comparison with the I-gel kept at room temperature.

Effects of antithrombin and gabexate mesilate on disseminated intravascular coagulation: a preliminary study.

PURPOSE: We hypothesized that antithrombin is more effective for disseminated intravascular coagulation (DIC) than is gabexate mesilate, which is a protease inhibitor, suggested from the previous studies. Initially, we compared the effects of antithrombin and gabexate mesilate for treating infection-related DIC. METHODS: Sixteen adult patients with a diagnosis of DIC with infection who were assessed with an acute DIC score 4 or higher at the admission to the intensive care unit were divided into antithrombin-treated and gabexate mesilate-treated groups. White blood cell counts, C-reactive protein, platelet counts, antithrombin, fibrin and fibrinogen degradation product, D-dimer, fibrinogen, thrombin antithrombin complex, plasmin plasminogen complex, prothrombin time, and activated partial thrombin time were measured on the day of admission and on days 1, 3, 5, and 7 thereafter. Mortality over 28 days was also compared. RESULTS: Platelet counts and antithrombin were significantly higher in the antithrombin group on day 7 and on days 5 and 7, respectively. Antithrombin increased to the normal level on day 1 in the antithrombin group but on day 7 in the gabexate mesilate group. C-reactive protein, fibrinogen degradation product, D-dimer, thrombin antithrombin complex, plasmin plasminogen complex, and prothrombin time were lower in the antithrombin group; but the differences were not significant. The 28-day mortality was 2 of 8 in the antithrombin group and 3 of 8 in the gabexate mesilate group, but they were not significantly different. CONCLUSIONS: Antithrombin may be a more effective treatment for coagulation and fibrinolysis disorders than gabexate mesilate in infection-related DIC, but there was no difference in 28-day mortality.

Anesthesia for bariatric surgery.

BACKGROUND: Bariatric surgery has a lot of problems in anesthesia. We retrospectively compared anesthesia for bariatric surgery in yellow race with that in normal weight patients. METHODS: Twenty patients who received bariatric surgery and 20 normal body weight patients who received abdominal surgery in Japan were enrolled. Induction condition, depth of epidural space, dose of anesthetics, duration of the effects of muscle relaxants, ventilation, and fluid management in bariatric surgery were analyzed and compared with those in normal body weight patients. RESULTS: An epidural catheterization was successful under ultrasound guide in the bariatric group. The depth epidural space was significantly larger in the bariatric group. Cormack and Lehane classification and the number of intubation attempt were not different between the two groups, while one bariatric case was once awakened to intubate blindly. Pressure-controlled ventilation was used in the bariatric group. Four bariatric patients were continuously ventilated after surgery. The doses of anesthetics and fluid infusion rate were not different between the two groups when calculated by ideal body weight in the bariatric group. The duration of the effects of rocuronium and pancuronium were shorter in the bariatric group. CONCLUSIONS: For anesthesia of yellow race patients undergoing bariatric surgery, intravenous anesthetics and acetate Ringer's solution with 1% glucose could be administered per ideal body weight, the effects of muscle relaxants lasted shorter, pressure-controlled ventilation could keep oxygenation with adequate carbon dioxide, and ultrasound assist was useful in epidural catheterization in the bariatric patients.

[The anxiety and types of problems encountered by homecare patients during an intermittent self-catheterization].

The aim of this study was to clarify why a homecare patient had an anxiety and the type of difficulties while having an intermittent self-catheterization at home. We used a questionnaire survey to conduct an oral interview for 25 homecare patients, who regularly had an intermittent self-catheterization. The survey results were codified into single phrase units of meaning, and then separated into categories. The results revealed that 70 to 80% of patients who had an intermittent self catheterization in their own homes experienced an anxiety and encountered difficulties during the process. The findings emphasized the importance of providing a sort of support for homecare patients when they have an intermittent self-catheterization for the first time, as well as the importance of providing continued support until the patients are comfortable with the procedure. For a future support, these patients' anxiety need to be reduced and difficulties related to an intermittent self catheterization resolved during an outpatient visit.

[Self purchase of catheter supplies and the hardship associated with urinary homecare patients].

The aim of our study was to clarify how catheter products are purchased by urinary homecare patients and to find problems associated with such purchases. We conducted a survey using a self-made questionnaire for 26 catheterized patients from Prefecture A, who were regular outpatients of the urology department. The results indicated that 17 patients(65. 4%)purchased catheter supplies on their own(13 males and 4 females, the mean age was 57. 9 years). The products purchased by the 26 patients were diverse including urine bags, syringes, catheters and tissues paper. Seven of the 17 patients(41%)responded that purchasing catheter supplies on their own was difficult, and 8(47%)responded that purchasing catheter supplies was an economic burden for them. The cost of purchasing catheter supplies varied greatly among the patients, and the price range was from 400 yen to 12, 000 yen. The cost was generally associated with the feelings of economic stress: it happens every month; it is a burden for some patients who need them for life time.

[A study of the goods supply system from hospital to outpatients with intermittent self-catheterization(ISC)].

OBJECTIVES: This study investigated the current status of goods supplied by medical facilities to outpatients practicing ISC. METHODS: The status of goods supplied was investigated by interviewing 4 medical facilities and 26 outpatients practicing ISC, using a questionnaire. RESULTS: 1. Of all goods supplied for use by outpatients practicing ISC, 53. 0%were supplied by medical facilities. The outpatients bought some goods required for ISC by himself. Moreover, some goods were supplied by prescription. 2. When a hospital was consulted, while there were those to whom goods are not supplied from a hospital, there were those to whom much kinds and quantity are supplied from the hospital. As for the patient to whom many kinds and the goods of quantity are supplied, goods expense formed about 70% of ISC administration fee. DISCUSSION: In order to establish goods feed system, it was necessary to examine a common knowledge of the structure of goods supply to doctors or nurses and the validity of the ISC administration fee system from now on.

Comparison of ear and chest probes in transcutaneous carbon dioxide pressure measurements during general anesthesia in adults.

OBJECTIVE: For transcutaneous carbon dioxide pressure (tcPCO(2)) measurement, the probe on the trunk or extremities has been used for many years. Our previous study showed that chest was better than arm for tcPCO(2) monitoring. Recently, the ear probe has been developed. The accuracy of tcPCO(2) as a surrogate measurement of arterial carbon dioxide pressure (PaCO(2)) has not been compared between the measurement with probe on the chest and measurement with probe on the earlobe. This study compared the accuracy of tcPCO(2) measured on the chest and tcPCO(2) measured on earlobe during general anesthesia in adults using linear regression analysis and Bland-Altman plot. METHODS: Ten patients aged 30-70 years scheduled for abdominal surgery under general anesthesia were enrolled. TcPCO(2) by TCM4™ (Radiometer, Copenhagen, Denmark, TtcPCO(2)) with its probe on the chest, tcPCO(2) by Sentec™ (Sentec AG, Therwil, Switzerland, StcPCO(2)) with ear probe, end-tidal carbon dioxide pressure (EtCO(2)), and PaCO(2) were simultaneously measured at four different sets of EtCO(2) levels in each patient. In total, 40 measurements were performed. The Scatter plot and Bland-Altman plot were obtained. Correlation coefficient (R(2)) ≥0.70 and limits of agreement ≤4 mmHg were judged as significant. RESULTS: TtcPCO(2) showed significant positive correlation with PaCO(2) (R(2) = 0.80) but StcPCO(2) did not (R(2) = 0.55). TtcPCO(2) and PaCO(2), and StcPCO(2) and PaCO(2) had large limits of agreement (-6.56 mmHg, 4.21 mmHg and -11.05 mmHg, 7.64 mmHg, respectively). TtcPCO(2) and StcPCO(2) had no significant correlation (R(2) = 0.63) and large limits of agreement (-8.98 mmHg to 7.91 mmHg). CONCLUSION: During general anesthesia in adults, both TtcPCO(2) and StcPCO(2) were not interchangeable with PaCO(2), but only TtcPCO(2) had good positive correlation with PaCO(2).

Anesthesia for a 228-kg patient (body mass index, 90.6) undergoing laparoscopic sleeve gastrectomy.

We undertook anesthesia of a 40-year-old woman with body weight of 228 kg and body mass index (BMI) of 90.6 kg/m(2) who was undergoing laparoscopic sleeve gastrectomy. This case may be the largest known patient undergoing general anesthesia in our country. Anesthesia was induced in a 30° head-up position with midazolam, fentanyl, droperidol, and inhalation of sevoflurane and nitrous oxide without muscle relaxants, and maintained with propofol, remifentanil, and pancuronium under pressure-controlled ventilation. The Airway Scope could not be inserted into her mouth, but her trachea was successfully intubated with a Macintosh laryngoscope. Dosages of anesthetics and fluid infusion rate were calculated first per ideal body weight. Then, infusion of propofol and remifentanil and administration of muscle relaxant were controlled by bispectral index, hemodynamics, and train-of-four response, respectively. Postoperative 12-h pressure-controlled ventilation and pain management by subcutaneous infusion of fentanyl and droperidol were successful. Subcutaneous heparin 5,000 units twice per day postoperatively did not induce thromboembolism.

Influence of CLOCK on cytotoxicity induced by diethylnitrosamine in mouse primary hepatocytes.

The Clock gene is a core clock factor that plays an essential role in generating circadian rhythms. In the present study, it was investigated whether the Clock gene affects the response to diethylnitrosamine (DEN)-induced cytotoxicity using mouse primary hepatocytes. DEN-induced cytotoxicity, after 24h exposure, was caused by apoptosis in hepatocytes isolated from wild-type mouse. On the other hand, Clock mutant mouse (Clk/Clk) hepatocytes showed resistance to apoptosis. Because apoptosis is an important pathway for suppressing carcinogenesis after genomic DNA damage, the mechanisms that underlie resistance to DEN-induced apoptosis were examined in Clk/Clk mouse hepatocytes. The mRNA levels of metabolic enzymes bioactivating DEN and apoptosis-inducing factors before DEN exposure were lower in Clk/Clk cells than in wild-type cells. The accumulation of p53 and Ser15 phosphorylated p53 after 8h DEN exposure was seen in wild-type cells but not in Clk/Clk cells. Caspase-3/7 activity was elevated during 24h DEN exposure in wild-type cells but not in Clk/Clk cells. In addition, resistance to DEN-induced apoptosis in Clk/Clk cells affected the cell viability. These studies suggested that the lower expression levels of metabolic enzymes bioactivating DEN and apoptosis inducing factors affected the resistance to DEN-induced apoptosis in Clk/Clk cells, and the Clock gene plays an important role in cytotoxicity induced by DEN.

[Effect of heparin on the activated partial thromboplastin time in parturients receiving combined spinal and epidural anesthesia for caesarean section].

BACKGROUND: Although administration of heparin is a useful method for preventing deep venous thromboembolism, one limitation is the increased risk of bleeding. In this retrospective investigation, we evaluated the effect of heparin on the activated partial thromboplastin time (APTT) in parturients who received caesarean section under combined spinal and epidural anesthesia. METHODS: In order to prevent deep venous thromboembolism, heparin 5000 units twice daily, was subcutaneously given in 199 parturients who received caesarean section under combined spinal and epidural anesthesia. Measured APTT was compared between before and after administration of the heparin. RESULTS: The heparin extended APTT from 29.6 +/- 2.5 sec to 35.4 +/- 5.9 sec (P < 0.05). An extended APTT by 1.5 times or more was found in 1.1% of the patients. There was no deep thromboembolism nor increased bleeding, including intra-abdominal and epidural hematoma. CONCLUSIONS: Subcutaneously administered heparin, 5000 units twice daily, might have a role in preventing deep venous thromboembolism in parturients undergoing caesarean section. Strict vigilance, however, should be provided against increased bleeding associated with epidural hematoma in parturients with an indwelling epidural catheter.

[Fire caused by a spark of electric scalpel igniting alcoholic antiseptic containing chlorhexidine].

Fire accident is one of the most severe complications that can occur in the perioperative period. We report a case of an episode of electrosurgical burn. An 80-year-old woman was scheduled for ascending colectomy due to ascending colon carcinoma. The skin of the surgical site was sterilized with alcoholic antiseptic containing chlorhexidine before the operation. On coagulating the bleeding point of the subcutaneous fatty tissue, a spark of the electric scalpel ignited the alcoholic antiseptic. She had burn on her right thorax, lower abdomen and femoral region. Two-degree burn occupied 2% of the body surface and three-degree burn 3%. She underwent dermatoplasty 14 days later. Postoperative course was uneventful and she left the hospital on the 58th postoperative day. An alcoholic antiseptic is the most useful and has an immediate effect for preoperative disinfection of the skin according to the CDC guideline. However, electric scalpel and alcoholic use are always accompanied with the risk of ignition and sufficient caution is required.

[Effectiveness of potassium adsorption filter during intraoperative blood transfusion in patients with chronic renal failure].

Two patients with chronic renal failure on hemodialysis, received rapid transfusion of packed red blood cells (PRBCs) because of massive intraoperative bleeding. To eliminate the excessive potassium in PRBCs, a potassium adsorption filter (Kawasumi KPF-4, Kawasumi Laboratories, INC., Tokyo, Japan) was applied during surgery. The potassium adsorption filter successfully reduced the potassium concentration from 14.4-22.0 mEq x l(-1) to 1.9-3.7 mEq x l(-1). A potassium adsorption filter is a simple and useful alternative for removal of excessive potassium in PRBCs.

[Anesthetic management for cerebral aneurysm surgery in a patient with aortitis syndrome accompanied by lung edema].

A 48-year-old woman with aortitis syndrome underwent clipping of dissecting aneurysm of the left posterior inferior cerebellar artery following subarachnoid hemorrhage. Preoperative echocardiography demonstrated moderate aortic regurgitation and pulmonary hypertension. Intravenous infusion (1900 ml.day-1) was performed to avoid cerebral vasospasm, but the patient developed lung edema. She received delayed surgical treatment after the improvement of lung symptoms. Anesthesia was induced with fentanyl (0.1 mg), propofol (90 mg) and vecuronium (6 mg). Radial arterial flow was judged to be insufficient for cannulation, and a cannulation was therefore performed on the dorsal pedis artery. During induction of anesthesia, there was a significant decrease in the arterial pressure, that required a total of 32 mg of intravenous ephedrine. Following tracheal intubation, a central venous catheter was inserted and dopamine was continuously administered. The patient was positioned in the park bench position. We thought that the placement of the introducer for Swan-Ganz catheter was difficult under the position and Swan-Ganz catheter was not inserted. Anesthesia was maintained with sevoflurane, air, and oxygen. We continuously monitored the central venous pressure as an indicator of fluid balance. In this case, we monitored dorsal pedis arterial pressure directly, which might not be sufficiently reliable to predict the decrease in cerebral blood flow.