[Evaluation of efficiency of ACD-CPR and STD-CPR; a multi-institutional study].

We compared the efficacy of ACD-CPR and STD-CPR based on 64 multi-institutional reports. No significant differences were observed in the rate of restoration of spontaneous circulation (ROSC) and in cardiopulmonary parameters during CPR using the two methods. There were 5 cases in which cardiopulmonary parameters improved after switching from STD-CPR to ACD-CPR and, eventually, in two of them spontaneous circulation was restored. In the ROSC cases of both groups, ETCO2 and values of SpO2, PaO2, and systolic BP at 30 minutes were higher than those of non-ROSC cases. ETCO2 never exceeded 20 mmHg in the non-ROSC cases, but it was higher in the ROSC cases. ACD-CPR is a good choice when trained persons are present or when extra hands are available to continue the CPR.

[Clinical features and outcomes of mechanically ventilated patients with acute respiratory failure during treatment with immunosuppressive drugs].

We examined clinical features and outcomes of mechanically ventilated patient (n = 11) retrospectively who had developed acute respiratory failure during treatments with immunosuppressive drugs. The mean APACHE II score was 22.6, and the mean lung injury score was 2.9. In eight patients chest X-ray and computed tomography showed interstitial pneumonia. Fungus and/or cytomegalovirus were isolated most often from patients with interstitial pneumonia. Observed mortality (72.7%) was significantly (P < 0.001) higher than predicted mortality (45.1%) in the APACHE II score. Patients, who were complicated with septic shock caused by fungus infection, showed poor mortality. These results suggest that the fungus and cytomegalovirus infections might be associated with poor prognosis in patients with acute respiratory failure during treatment with immunosuppressive drugs.

Prothiofos metabolites in human poisoning.

CASE REPORT: A 63-year-old woman was admitted to a local hospital after the ingestion of 40% prothiofos preparation (Tokuthion) 370 mL. Gastric lavage was performed and cathartics, active charcoal, diuretics, atropine sulfate, and pralidoxime were administered. Serum cholinesterase activity was 1.3 IU/L (normal 200-460 IU/L). The patient's consciousness was gradually restored after 4 hours of charcoal hemoperfusion and she was discharged 5 days after admission with no sequelae. METHOD: Plasma and urine prothiofos and metabolites were detected by gas chromatography-flame photometry and gas chromatography-mass spectrometry. Two despropyl metabolites were synthesized for identification and estimation. RESULTS: The main metabolites were identified with authentic prothiofos and methyl esters of synthesized des-S-propyl prothiofos oxon (O-2,4-dichlorophenyl O-ethyl phosphate), despropyl prothiofos oxon (O-2,4-dichlorophenyl O-ethyl phospholothiolate), and des-S-propyl prothiofos (O-2,4-dichlorophenyl O-ethyl phosphorothioate). Despropyl prothiofos (O-2,4-dichlorophenyl O-ethyl phosphorodithioate) was also identified in plasma. Large amounts of the hydrolyzed product, 2,4-dichlorophenol and its conjugate were also found. The metabolic pattern of prothiofos in humans appears to be different from that in rats.

In vitro effects of propofol on blood coagulability and fibrinolysis by the use of thromboelastograph technique.

BACKGROUND: To investigate the in vitro effects of propofol on blood coagulability and fibrinolysis by the use of thromboelastograph (TEG) technique. METHODS: The blood samples, obtained from 14 healthy volunteers, were divided into two groups: propofol (n = 7) and intralipid (n = 7), and 360 microliters volumes of whole blood were incubated with 2 microliters of 1% propofol and with its solvent intralipid, respectively. The incubated sample was then used for TEG measurements. RESULTS: The maximum amplitude (MA), which reflects coagulability, in the intralipid group significantly increased by about 7% and 16% compared to the control and propofol groups, respectively (P < 0.05), whereas the MA in the propofol group did not change. The fibrinolytic rate (FR) in the propofol group significantly increased by about 170% and 210% compared to the control and intralipid groups, respectively (P < 0.05), whereas the FR in the intralipid group did not change. CONCLUSIONS: Propofol, per se, has at the concentration of 55.6 micrograms.ml-1 an in vitro accelerative effect on blood fibrinolysis detected by TEG.

[Small cell lung cancer associated with paraneoplastic cerebellar degeneration and Lambert-Eaton myasthenic syndrome].

A 57-year-old man was admitted to our hospital in November 1997 because of dysarthria, progressive ataxia, generalized weakness, and incoordination in both hands. He had been aware of the dysarthria 6 months earlier. Chest roentgenograms and computed tomographic films disclosed a 5 cm x 6 cm mass in the left S3b. The patient was given a diagnosis of small cell lung cancer (T3N2M0, stage IIIA) associated with paraneoplastic cerebellar degeneration (PCD). Three courses of chemotherapy (carboplatin and etoposide) eliminated the tumor and slightly alleviated the PCD symptoms. In March 1998, electromyograms revealed a fall in the single-stimulated M wave and a waxing phenomenon that had not been observed on admission. Anti-P/Q type voltage gated calcium channel antibody was detected in serum samples obtained on admission and after chemotherapy. These findings confirmed an association with Lambert-Eaton myasthenic syndrome. No relapse of the tumor has been observed 15 months after the last course of chemotherapy.

Surgical/tourniquet pain accelerates blood coagulability but not fibrinolysis.

Tissue damage during surgery induces coagulation factors and activates platelets. Surgical pain may provoke release of catecholamines, leading to hypercoagulability. We have investigated the effect of surgical pain on blood coagulability and fibrinolysis in orthopaedic operations using tourniquets in 22 patients undergoing total knee replacement. Patients were allocated to one of two groups to receive extradural anaesthesia (EA; n = 11) or general anaesthesia (GA; n = 11). The EA group received lumbar extradural block with lidocaine. The GA group received only general anaesthesia, maintained with 1.5-2.5% sevoflurane and 66% nitrous oxide in oxygen. Using a thrombelastogram technique, blood coagulability and fibrinolysis were measured. Mean maximum amplitude (MA), which reflects coagulability, increased after tourniquet inflation (11%) in group GA whereas MA in group EA did not change. After tourniquet deflation, MA values in both GA and EA groups increased significantly (10% and 20%, respectively) (P < 0.05), and there was also a significant difference in MA between groups (P < 0.05). The fibrinolytic rate did not change in either group during tourniquet inflation, but increased significantly (160%) after tourniquet deflation. There was no significant difference in fibrinolytic rate between the groups. We conclude that the hypercoagulability seen in group GA could have been caused by surgical or tourniquet pain, or both, and that extradural anaesthesia is a useful technique to prevent hypercoagulability.

[The effect of scalp infiltration with bupivacaine on blood coagulability and fibrinolysis in neurovascular surgery].

We investigated the effect of scalp infiltration with bupivacaine on blood coagulability and fibrinolysis in neurovascular surgery. Patients were randomly divided into two groups: scalp infiltration group (who received scalp infiltration with 0.5% bupivacaine prior to surgical incision, n = 7) and control group (n = 6). The blood coagulability and fibrinolysis were measured before and after surgical incision using a thromboelastogram (Thromboelastograph C-3000, Haemoscope). In the control group, the reaction and coagulation times were significantly shortened (30% and 23%, respectively, P < 0.05) and the maximum amplitude, which reflects coagulability, increased significantly (21%, P < 0.01) compared to each presurgical value. The scalp infiltration prior to the surgical incision prevented these reactions (P < 0.05). The fibrinolytic rate did not change in either group. We conclude that scalp infiltration prior to surgical incision is beneficial for attenuating an increase in blood coagulability, which could induce perioperative complications due to associated systemic diseases (i.e. hypertension, diabetes, ischemic heart disease, etc.).

[A case of emergency admission for CO2 narcosis in a patient with amyotrophic lateral sclerosis].

A 68-year-old man with severe dyspnea was admitted as an emergency case. He had no past history of any respiratory or neuromuscular diseases. Immediately after insufflation of oxygen, respiratory arrest occurred. The blood gas analysis showed hypoxemia and severe hypercapnia (PaO2; 32 mmHg, PaCO2; 127 mmHg). We diagnosed as CO2 narcosis, and he was treated with a respirator in the ICU. He showed nonflaccid bilateral diaphragmatic paralysis and muscle atrophy of the upper extremities. As the EMG showed giant spikes of neurogenic pattern, he was diagnosed as ALS. Weaning from the respirator failed because of his respiratory muscle fatigue. He was given rehabilitation during the day time and ventilatory support with the respirator during the night. We conclude that if we meet with an emergency patient with CO2 narcosis without any pulmonary disorder, we have to suspect neuromuscular diseases, e.q. ALS. In some of such cases, mechanical ventilation supports social rehabilitation.

[Influence of epidural and spinal block on VO2 and VCO2 measured by the indirect calorimetry].

We evaluated the influence of epidural and spinal anesthesia on VO2 and VCO2 measured by the indirect calorimetry. According to the spreading of anesthetic level, VO2, VCO2 and EE increased in the epidural group (EP group), but they decreased in spinal group (SP group). RQ was unchanged in both groups. Rate pressure product (RPP), in proportion to the MVO2 and the REE, did not correlate with the EE. The VO2, VCO2 and EE in EP group increased probably because; (1) epidural anesthesia does not affect the VO2 change, as it does not markedly suppress respiration; (2) cardiac stroke work is retained during epidural anesthesia, as it does markedly suppress circulation. In conclusion, epidural anesthesia exerts less influence on the respiratory and circulatory systems of patients compared with spinal anesthesia.

[Changes in 3 different kinds of body temperature during CPR for DOA patients].

We monitored 3 different kinds of temperature (the tracheal, forehead deep and rectal) during CPR for 8 DOA patients. The forehead deep temperature rose slowly from room temperature, and gradually reached the tracheal temperature. The rectal temperature, except for 2 cases, almost immediately exhibited a temperature close to the tracheal temperature. In 2 exceptions, the rectal temperature exhibited a much lower value than the other temperature monitors. On the other hand, the tracheal temperature seemed to represent the core temperature in all cases during CPR. In conclusion, the tracheal temperature is useful for the monitoring of the patient's temperature during CPR because it represents the core temperature and endotracheal intubation is essential for CPR.

[A case of postoperative hepatic injury after sevoflurane anesthesia].

A 63 year old man underwent MCA aneurysmal neck clipping under O2-N2O-enflurane anesthesia. On the 46th postoperative day after the first operation, he had cranioplasty under O2-N2O-sevoflurane anesthesia. Hepatic injury occurred after the operation, and GOT, GPT and bilirubin increased above 700 IU.l-1, 800 IU.l-1 and 15.0 mg.dl-1 respectively but consciousness disturbance, hyperammonemia and DIC did not appear. His hepatic injury improved on conservative therapy. It seems that his hepatic injury was not caused by hepatitis viruses or hepatotoxicity of any drugs, but caused by cross sensitization between halogenated inhalation anesthetics, especially enflurane and sevoflurane, judging from drug induced lymphocyte stimulating test (DLST). We have to select an anesthetic method considering potential hepatic injury by halogenated anesthetics in a case of repeated anesthesia and operations during a short-term.

[Acute pulmonary edema in five patients undergoing sevoflurane anesthesia].

Four adults and a child undergoing surgery with sevoflurane anesthesia developed acute pulmonary edema immediately after anesthesia. Prior to development of pulmonary edema all patients exhibited severe arterial hypertension and tachycardia. Their episodes of circulatory changes were, we believed, caused by the local injection of epinephrine for hemostasis in 2 patients (9 y.o. child, 45 y.o. man) and the intrusion of painful surgical stimuli in one patient (67 y.o. man). Circulatory changes in these three patients were treated by increasing the inspired sevoflurane concentration. We, however, speculate that the increase in inspired sevoflurane decreased the cardiac output and that the resulting increase in pulmonary wedge and capillary pressures was caused by an abrupt increase of arterial blood pressure, followed by a rapid increase in afterload due to cardiac suppression from the high concentration of sevoflurane. In 2 patients (74 y.o. man, 61 y.o. woman) arterial hypertension occurred during endotracheal extubation after sevoflurane anesthesia. Because of fast uptake and elimination of sevoflurane due to a low blood/gas partition coefficient, a fast awakening in the latter 2 patients, may be responsible for the abrupt increase in arterial blood pressure. In conclusion, it should be noted that pulmonary edema may be involved when severe circulatory changes occur in a patient undergoing sevoflurane anesthesia.

[Effects of high-dose fentanyl on intraductal pressure in the choledochoduodenal junction in dogs].

Changes in intraductal pressure in choledochoduodenal junction were studied following intravenous administration of fentanyl in dogs. The intraductal pressure was measured with constant-rate infusion method. A statistically significant increase in the intraductal pressure was demonstrated after the intravenous administration of fentanyl 5 micrograms.kg-1 and 75 micrograms.kg-1. The increase in intraductal pressure following fentanyl administration at a dose of 75 micrograms.kg-1 persisted for more than 5 hours. We conclude that in case of intravenous high-dose fentanyl administration special attention should be paid to spasm of choledochoduodenal sphincter.

[Effects of ketamine on behavioral responses to somatic and visceral stimuli in rats].

The responses to colorectal distension as a visceral stimulus were observed and tail-flick test was performed in rats, after intraperitoneal administration of ketamine 30 mg.kg-1 (n = 6) or 100 mg.kg-1 (n = 5). After determining control colorectal distension and tail-flick values, both procedures were repeated every 10 minutes for one hour in both groups. The control thresholds for colorectal distension and tail-flick latencies were 20.8 +/- 1.0 mmHg and 4.5 +/- 0.3 sec (mean +/- SD), respectively in ketamine 30 mg.kg-1 group. They were 21.2 +/- 1.1 mmHg and 4.7 +/- 0.4 sec in ketamine 100 mg.kg-1 group. These baseline threshold and latency values in the two groups were not significantly different. Ten minutes after ketamine administration, the colorectal distension thresholds and tail-flick latencies were 43.7 +/- 7.2 mmHg and 6.4 +/- 0.9 sec, respectively in ketamine 30 mg.kg-1 group. They were 53.3 +/- 14.8 mmHg and 7.2 +/- 0.8 sec, respectively in ketamine 100 mg.kg-1 group. These values were significantly greater than the preketamine control values in both groups. The present study demonstrates that ketamine exerts apparent analgesic effects against both visceral and somatic stimuli. These results led us to consider that ketamine may be clinically useful to control visceral pain.

[Comparison of the effect of propofol and that of pentobarbital on behavioral responses to somatic and visceral stimuli in rats].

The behavioral responses to tail-flick and colorectal distension after intraperitoneal administration of either small or large dose of propofol as well as of pentobarbital were studied in rats. Immediately after baseline testing, animals were randomly divided into four groups; propofol groups of 50 mg.kg-1 (n = 4) or 100 mg.kg-1 (n = 4) and pentobarbital groups of 10 mg.kg-1 (n = 4) or 20 mg.kg-1 (n = 4). Both tests were repeated every 10 minutes for 1 hour in each group. There were no changes in the thresholds of colorectal distension and tail-flick latencies in those animals receiving small doses of propofol and pentobarbital. The thresholds for colorectal distension following administration of large doses of propofol and pentobarbital had greatly increased at 10 minutes and this increase persisted for about 30 minutes although it declined gradually. In contrast, the state of high sensitivity to tail-flick test was seen in the large dose groups of both drugs. It is concluded that there are no pharmacological differences between propofol and pentobarbital in behavioral responses to somatic and visceral stimuli in rats.

Effects of thoracic epidural anesthesia on myocardial pH and metabolism during ischemia.

The effect of thoracic epidural anesthesia (TEA) on the ischemic myocardium was examined in open-chest dogs anesthetized intravenously. Ischemia induced by brief coronary artery occlusion caused an elevation of the ST segment in epicardial ECG and a reduction in myocardial pH and contractile force. TEA with 0.15 ml/kg of 0.4% bupivacaine solution attenuated an ischemia-induced decrease in myocardial pH and an increase of the ST segment in epicardial ECG. This attenuation was maintained even after the restoration of blood pressure and heart rate, which had been decreased significantly after TEA, to pre-TEA levels, suggesting that a beneficial effect of TEA should not be confined to its hemodynamic changes such as decreased blood pressure and heart rate. In contrast, the subendocardial contents of ATP, creatine phosphate (CP) and lactate were not affected by TEA, either in the presence or the absence of 5 min LAD occlusion. These results suggest that neither hemodynamic nor metabolic changes are responsible for the reduced myocardial ischemic acidosis induced by TEA after brief coronary artery occlusion. The acidosis-saving property of TEA is favorable for the ischemic heart.

[Effects of lactation on pregnancy induced analgesia during the postpartum period in rats].

Activation of an endogenous opioid system has been associated with an elevation in pain threshold during late pregnancy and the early postpartum period in rats. It is well established that endogenous opiates are involved in the physiological regulation on prolactin secretion. This study examined the influence of lactation on pregnancy-induced analgesia during the early postpartum period in rats. Three tests (colorectal distension, tail-flick and hot-plate) were used to assess each animal's response to painful stimuli. After determining pregnant baseline values, one group of rats (lactating, n = 21) were mated and retested on Day 7 and 21 of gestation and 1, 3, 5, 7 and 14 days after parturition. A non-lactating group of animals (n = 14) whose pups were removed immediately after delivery was tested in the same manner. On Day 21 of gestation significantly higher thresholds and longer latencies were observed. On Day 1 and 3 in both lactating and non-lactating rats, the values were still elevated. No significant difference was observed during the early postpartum period between the two groups. This study confirms the existence, in rats, of pregnancy-induced analgesia late in pregnancy and the early postpartum period. The analgesia during the early postpartum period is not influenced by lactation.

[Anesthetic management of caesarean section in a patient with idiopathic thrombocytopenic purpura and placenta praevia].

A 24-year-old female with idiopathic thrombocytopenic purpura (ITP) and total placenta praevia was scheduled for caesarean section. Anesthetic management during caesarean section with ITP and placenta praevia is critical because of possibility of massive intra- and postpartal bleeding. The patient received prednisolone 30 mg per day for 10 days before surgery. Bleeding time and value of platelet count returned to normal range on the operative day. Hydrocortisone 100 mg and atropine sulfate 0.3 mg were given intravenously just before the start of anesthesia. Anesthesia was induced with thiamylal 4 mg.kg-1 and SCC 1 mg.kg-1 and maintained with N2O-O2-enflurane. A baby girl was delivered after 7 min, and the Apgar score was 9 at 1 min after delivery. Intraoperative bleeding totaled 1,314 ml, but we could avoid total hysterectomy.