Oxygen ultra-fine bubbles (OUB) saline injection prevents bone loss of glucocorti\coid-induced osteoporosis in mice, and OUB inhibit osteoclastogenesis via RANK-TRAF6-c-Fos-NFATc1 signaling and RANK-p38 MAPK signaling in vitro.

2004年に制定されたわが国の「肺血栓塞栓症/深部静脈血栓症 (静脈血栓塞栓症) 予防ガイドライン」の参考とされた米国胸部疾患学会 (ACCP) のガイドラインが2008年に改定され第8版となった. ACCPガイドライン第8版では低分子量ヘパリンが未分画ヘパリンより優先されており, 合成第Ｘa因子阻害薬フォンダパリヌクスの推奨が増加した.

We experienced difficult airway management in a 65-year-old woman with acute dyspnea due to bilateral recurrent nerve palsy suffering from severe rheumatoid arthritis for fifty years. Her cervical spine was ankylosed and could not be extended at all. Tracheostomy was planned under local anesthesia because of difficulty of endotracheal intubation, possibility of airway obstruction and laryngeal edema. In this condition, the surgical area was narrow and difficult to approach. The surgical bleeding and blood-aspiration into the tracheostomy site occurred followed by airway obstruction. A rigid tracheal tube could not be inserted through the tracheal incision and SpO2 decreased to 81%. We inserted a percutaneous cricothyroidotomy cannula through the tracheal incision and superimposed HFJV on her spontaneous ventilation. Assisting the ventilation in this way finally, a spiral endtracheal tube was inserted and her oxygenation became stable.

BACKGROUND:Although powdered latex surgical gloves are predominantly used in Japanese healthcare facilities, the prevalence of latex sensitization among anesthesiologists has not been investigated.METHODS:The authors surveyed 60 anesthesiologists of 16 facilities with questionnaires and measurements of specific IgE antibodies against latex and other aeroallergens by AlaSTAT microplate immunoassay. Sensitization was defined as positive if the specific IgE concentration was not less than 0.70 IU x ml(-1).RESULTS:With surgical gloves 63.3% of anesthesiologists used powdered latex gloves, compared to 10.2% with examination gloves. The prevalence of latex sensitization was 33.3%, with a peak of 70% (7/10) in ages 45-49. In multivariate analysis, anesthesiologists of the facilities where more than 50% of them used powdered latex surgical gloves had a 6.0-fold risk of latex sensitization (95% CI 1.7-21.5; P=0.006). Histories of atopic dermatitis, asthma, or food allergy were also considered as risk factors (OR 3.8; 95% CI 1.1-13.7; P=0.038). The history of allergic rhinoconjunctivitis was not associated with latex allergen, but with Japanese cedar pollen. No relation was observed between latex and timothy pollen.CONCLUSIONS:Our results suggest that surgical powdered latex gloves were the major predisposing factor for latex sensitization measured by latex-specific IgE among anesthesiologists.

Many complications after spinal anesthesia have been reported, but diplopia is rare. We had four cases of diplopia in 794 cases of spinal anesthesia in three years at Nara Medical University Hospital. These 4 cases were not characterized by any major factors including gender, age, or anesthetic choice. However, two of them were accompanied with post-spinal headache. Diplopia in three cases improved spontaneously, but one finally required epidural blood patch for the persistent diplopia. Lack of concern regarding the possibility of post-spinal diplopia among medical staffs might be common because this incidence is really rare. However, we need to know the possibility of this neurological sequel after spinal anesthesia. We would like to propose that the informed consent regarding spinal anesthesia should include the possibility of this complication and anesthesiologists should perform intensive neurological examinations after spinal anesthesia concerning post-spinal diplopia.

1999年1月から2003年12月までの5年間の小児待機手術症例 (12歳以下, 812例) を対象として, 術後麻酔科外来での問診により得られた結果から, 麻酔の満足度や周術期苦痛因子について検討した. 麻酔に対する満足率は60.8%で, 不満率は2.3%であった. 周術期の苦痛因子は32.0%に訴えがあり, 点滴注射, 術後創部痛, 麻酔前投薬, 尿道カテーテル, 術後嘔気・嘔吐の順に多かった. また手術決定時の麻酔説明を追加することにより不満率は減少し, 入院後の手術延期症例は有意に減少した. 小児待機手術においては, 麻酔の安全性と上記の問題点を考慮した麻酔の説明や麻酔管理が必要であり, 親の理解を得るためには, 手術決定時の麻酔説明と説明機会を増やすことが有用と考えられた.

1998年11月から2001年12月の間に, 待機手術を脊髄くも膜下麻酔(以下, 脊麻)で行い, 手術後麻酔科外来を受診した症例(898症例)に対して問診を行い, 脊麻後合併症の発生率と脊麻に対する患者の満足度について評価, 検討した. 脊麻後の合併症は女性に多く, 年齢別では13～39歳に多く, 年齢とともに減少する傾向にあった. 麻酔満足度は, 不満と訴える割合が7.8%で, その要因として, 不十分な手術中の鎮痛効果やくも膜下穿刺に関するものが多く認められた. 脊麻は手術中に意識があり, 患者にとり大きなストレスとなるため, 麻酔方法の決定には患者が納得できる麻酔方法を選択してもらう努力が必要である.

Editor—We read with interest the paper by Inoue and colleagues1Inoue S Nishimine N Kitaguchi K Furuya H Taniguchi S. Double lumen tube location predicts tube malposition and hypoxemia during one lung ventilation.Br J Anaesth. 2004; 92: 195-201Crossref PubMed Scopus (78) Google Scholar describing the importance of left double lumen tube (L-DLT) malpositioning during one-lung ventilation (OLV) and the prevalence of hypoxaemia. The authors defined their correct DLT position according to Slinger2Slinger PD. Fiberoptic bronchoscopic positioning of double-lumen tubes.J Cardiothorac Anesth. 1989; 3: 486-496Abstract Full Text PDF PubMed Scopus (97) Google Scholar as ‘an unobstructed view into the left upper and lower lobe bronchus through the endobronchial lumen with the bronchial cuff immediately below the carina and just visible in the main left bronchus through the tracheal lumen’. They defined malposition ‘if the tube had to be moved (in or out) by more than 1.0 cm to correct its position’. We disagree with their definition of DLT malpositioning. Clinically, a malpositioned L-DLT occurs when the tube obstructs the left upper lobe bronchus or when the top of the endobronchial cuff is above the carina. This type of malpositioning may explain desaturation or insufficient lung separation. A position between these two extremes has no clinical significance and should be considered inside the margin of safety. The authors did not report the type of malpositioning they encountered (proximal or distal), and it seems to us that a 1 cm displacement is difficult to evaluate by fibreoptic bronchoscopy. Finally, the authors discussed ‘how can we stop DLTs becoming misplaced? We have no solution so far, ….’ We would like to highlight the fact that the L-DLT was redesigned in 1994 to increase its margin of safety.3Yahagi N Furuya H Matsui et al.Improvement of the left Broncho-Cath double-lumen tube.Anesthesiology. 1994; 81: 781-782Crossref PubMed Scopus (2) Google Scholar These modifications cause problems when the tube is positioned using the classic approach,2Slinger PD. Fiberoptic bronchoscopic positioning of double-lumen tubes.J Cardiothorac Anesth. 1989; 3: 486-496Abstract Full Text PDF PubMed Scopus (97) Google Scholar and the patient is therefore placed in lateral decubitus before checking the L-DLT position.4Klein U Karzai W Bloos F et al.Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia.Anesthesiology. 1998; 88: 346-350Crossref PubMed Scopus (192) Google Scholar We conducted a study to address the problem of L-DLT malpositioning and described a new method of positioning by visualizing the carina through the transparent wall of the L-DLT.5Fortier G Coté D Bergeron C Bussieres JS. New landmarks improve the positioning of the left Broncho-Cath double-lumen tube-comparison with the classic technique.Can J Anaesth. 2001; 48: 790-794Crossref PubMed Scopus (23) Google Scholar This new method necessitated less re-positioning of the L-DLT than the classic technique (23% compared with 53%), and should be use routinely in thoracic surgery. Editor—Thank you for giving us the opportunity to reply to this interesting letter. We agree with the comment that we used the classic definition by Slinger2Slinger PD. Fiberoptic bronchoscopic positioning of double-lumen tubes.J Cardiothorac Anesth. 1989; 3: 486-496Abstract Full Text PDF PubMed Scopus (97) Google Scholar for DLT positioning and we would have had different results if we had used the new definition described by Fortier and colleagues.5Fortier G Coté D Bergeron C Bussieres JS. New landmarks improve the positioning of the left Broncho-Cath double-lumen tube-comparison with the classic technique.Can J Anaesth. 2001; 48: 790-794Crossref PubMed Scopus (23) Google Scholar However, the main point that we would emphasize is that patients who have DLT malposition after being placed patient in the lateral position had more DLT malposition and hypoxaemia during OLV.1Inoue S Nishimine N Kitaguchi K Furuya H Taniguchi S. Double lumen tube location predicts tube malposition and hypoxemia during one lung ventilation.Br J Anaesth. 2004; 92: 195-201Crossref PubMed Scopus (78) Google Scholar Using either definition of DLT positioning, classic or new, malposition will occur in some cases. It has been reported that even with the new positioning method, 23% of patients developed DLT malposition, although this technique substantially reduced its incidence.5Fortier G Coté D Bergeron C Bussieres JS. New landmarks improve the positioning of the left Broncho-Cath double-lumen tube-comparison with the classic technique.Can J Anaesth. 2001; 48: 790-794Crossref PubMed Scopus (23) Google Scholar We think that some patients are more susceptible to intraoperative factors inducing DLT malposition and more easily develop hypoxaemia during OLV. In our report, we discussed how we can stop DLTs becoming misplaced, but missed the opportunity to comment on the new approach to DLT positioning. We really appreciate the new positioning method. Regarding our definition of DLT malposition, we think that it is correct when using ‘classic approach’ for DLT placement. In fact, Klein and colleagues used the same classic approach but a more strict definition for DLT malpositioning, which was evaluated by fibreoptic bronchoscopy.4Klein U Karzai W Bloos F et al.Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia.Anesthesiology. 1998; 88: 346-350Crossref PubMed Scopus (192) Google Scholar As mentioned in our report, patients with DLT malposition met the bronchoscopic criteria for DLT malposition of Campos and colleagues,6Campos JH Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker.Anesth Analg. 2003; 96: 283-289Crossref PubMed Google Scholar which is very similar to the clinical malposition that Fortier and colleagues5Fortier G Coté D Bergeron C Bussieres JS. New landmarks improve the positioning of the left Broncho-Cath double-lumen tube-comparison with the classic technique.Can J Anaesth. 2001; 48: 790-794Crossref PubMed Scopus (23) Google Scholar define in their article and letter. In addition, we should note that most of our patients developed proximal malposition. Lastly, we accept that as just over 1.0 cm of movement can cause clinical malposition, we should use the new approach instead of the classic one in future. S. Inoue N. Nishimine K. Kitaguchi H. Furuya S. Taniguchi Kashihara, Japan

Background. Poor positioning of an endobronchial double lumen tube (DLT) could affect oxygenation during one lung ventilation (OLV). We set out to relate DLT position to hypoxaemia and DLT misplacement during OLV.Methods. We recruited 152 ASA physical status I-II patients about to have elective thoracic surgery. The trachea was intubated with a left-sided DLT. Tube position was assessed by fibre-optic scope and correction was made after patient positioning and during OLV. If Pa-O 2 was less than 10.7 kPa, the DLT position was checked and then PEEP, continuous positive airway pressure (CPAP), oxygen insufflation, or two lung ventilation (TLV) were tried.Results. The DLT was found to be misplaced in 49 patients (32%) after patient positioning, and in 38 patients (25%) during OLV. PEEP to the dependent lung, CPAP or apneic oxygen insufflation to the non-dependent lung, or brief periods of TLV, were applied in 46 patients (30%). Patients who had DLT malposition after placing the patient in the lateral position had a greater incidence of DLT malposition during OLV (59 vs 9%) and also required each intervention more frequently (57 vs 10%). Patients with DLT malposition during OLV also required interventions more often (84 vs 12%).Conclusions. Patients who have DLT malposition after placing the patient in the lateral position had more DLT malposition during OLV and hypoxaemia during OLV.

BACKGROUND:Postoperative nausea and vomiting are important complications after craniotomy.METHODS:One hundred and seventy eight patients who had undergone brain tumor resection at Nara Medical University were retrospectively divided to one of two groups; with or without PONV within 24 hours postoperatively. Variables compared between the groups include gender, age, weight, height, site of surgery (supratentorial versus infratentorial craniotomy), size of brain tumor, type of anesthesia (inhalation versus intravenous anesthesia with nitrous oxide), intraoperative fentanyl dose, duration of surgery as well as anesthesia, and intraoperative posture.RESULTS:PONV occurred in 87 patients (49%). The incidence of PONV in patients undergoing infratentorial craniotomy was significantly higher than that in patients undergoing supratentorial craniotomy (75% vs 45%, P = 0.0011). There were no significant associations between PONV and other variables analyzed.CONCLUSIONS:These results indicate that the incidence of PONV after brain tumor resection is high and infratentorial surgery is a risk factor for PONV. Strategies for the prevention of PONV after craniotomy are required.

To clarify the present state of local institutional guideline for perioperative deep thrombosis and pulmonary embolism in individual hospitals, a questionnaire was sent to anesthesia departments in Japan. According to the replies, 82 hospitals have original guidelines. Forty of them reported the contents of their guidelines. However, 37 hospitals have some problems regarding their guidelines. Cost for these perioperative managements and application of spinal or epidural anesthesia for heparinized patients appears to be commonly recognized as pending questions in their guideline. It seems to be difficult to make a stereotyped standard guideline in Japan because each local guideline has a specific strategy according to their situations. However, it is needless to say that a further nationwide survey and collaboration, and governmental support for these diseases would be required.

Background: Intrathecal epinephrine can produce prolongation of duration of spinal anaesthesia by reducing vascular absorption of the local anaesthetics. The patient's positioning can change the cephalad spread of hyperbaric local anaesthetics by affecting the lordosis of the vertebral canal. These factors combined are expected to affect the cephalad spread of sensory block levels. The purpose of this study was to investigate whether combined use of epinephrine with hyperbaric tetracaine in the supine position can enhance the cephalad spread of sensory block levels compared with hyperbaric tetracaine alone in the lithotomy position.Methods: ASA physical status I or II 48 urological (lithotomy group) and 48 orthopaedic patients (supine group) scheduled to undergo elective surgical procedures in the lithotomy or supine position under spinal anaesthesia were enrolled. Patients in each group were randomly divided into two subgroups to receive intrathecal 10 mg of hyperbaric tetracaine with or without 0.2 mg of epinephrine (Groups L, LE, S, and SE). The extent of sensory blockade was assessed by loss of cold sensation. After achievement of sensory blockade up to T10, the patients in Groups L and LE were immediately placed in the lithotomy position. Patients in Groups S and SE were maintained in the supine position.Results: The highest sensory blockade in the SE Group was on average statistically significantly higher than in the L Group. The mean time taken to the highest sensory blockade in the SE Group was statistically significantly longer than in Groups L and S. Atropine for bradycardia was used more frequently in the SE Group than in the other groups.Conclusions: Combined use of epinephrine with hyperbaric tetracaine in the supine position can enhance the cephalad spread of sensory block levels compared with hyperbaric tetracaine alone in the lithotomy position.

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.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.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.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.

To investigate whether motor evoked potentials (MEP) to transcranial electrical stimulation under constant blood propofol concentration are affected by the arousing effect of surgical noxious stimuli.

BACKGROUND:We evaluated the hemodynamic efficacy of combined cathecholamine and three different continuous infusion doses of olprinone (0.05, 0.1, 0.3 microgram.kg-1.min-1) in 24 cases (0.05 group: 8 cases, 0.1 group: 8 cases, 0.3 group: 8 cases) undergoing coronary artery bypass grafting (CABG).METHODS:Olprinone was administered as a single dose (0.1 mg.kg-1) into the venous reservoir of the CPB circuit 15 min prior to the end of emergence from CPB, followed by continuous infusion. Hemodynamics were measured at the time of preCPB (M 0), just after the end of CPB (M 1), pre chest closure (M 2) and after chest closure (M 3). Cathecholamines were used to maintain mean arterial pressure (> 65 mmHg) and cardiac index (> 3.0 l.min-1.m-2). Hemodynamics (at M 0, M 1, M 2 and M 3) and the number of cases requiring combined cathecholamine were compared among the 3 doses.RESULTS:Three doses showed no significant difference on hemodynamics. In the number of cases requiring combined cathecholamine, group 0.3 were significantly lower than group 0.05 at dobutamine, and group 0.05 were significantly higher than group 0.1 and 0.3 at norepinephrine.CONCLUSIONS:The higher continuous infusion dose of olprinone (0.3 > 0.1 > 0.05 microgram.kg-1.min-1) can diminish the number of cases requiring combined cathecholamine administration during coronary artery bypass grafting.

In hypothermic patients, a tendency to bleed may be observed even when hemostatic tests seem to be normal. Coagulation and platelet function tests are usually performed at 37degreesC. We investigated the influence of induced hypothermia on temperature-adjusted hemostasis function testing using Sonoclot Analyzer(R) (Sonoclot(R)) and Thromboelastography(R) (TEG(R)). Anesthesia was induced and maintained with IV ketamine and fentanyl on 15 male New-Zealand White rabbits. A water blanket was used to induce hypothermia to 30degreesC and to rewarm to 37degreesC. Blood samples were obtained at four points: before hypothermia, at 34degreesC, at 30degreesC, and after rewarming. Standard coagulation tests were performed at 37degreesC (C method), and simultaneously, real temperature hemostasis function tests (R method) were run. In Sonoclot(R), activated clotting time and time to peak increased and clot rate decreased significantly at 30degreesC in the R method compared with those in the C method. In TEG(R), reaction time and clot formation time were prolonged and clot formation rate was diminished at 30degreesC in the R method compared with those in the C method. Induced hypothermia delayed the coagulation cascade and reduced platelet function. During hypothermia, hemostatic measurements should be performed at real temperature to avoid overestimating patient hemostatic function based on results measured at the standard 37degreesC.

BACKGROUND During cardiopulmonary bypass (CPB), several factors affect drug disposition and action. This topic has not been studied extensively during normothermic CPB. In this study, we related propofol dose to plasma propofol concentration and burst suppression of the EEG during normothermic bypass. METHODS After institutional approval and informed consent, 45 patients having cardiac surgery were assigned randomly to receive propofol infusions at 4 (Group A), 5 (Group B) and 6 (Group C) mg kg(-1) h(-1) during normothermic CPB. In all patients, small to moderate doses of fentanyl were also administered. Plasma propofol concentration and burst suppression ratio (BSR) were measured at the following times: (1) 10 min before CPB, (2) 10 min after the start of CPB, (3) 30 min after the start of the CPB, (4) just after aortic declamping, and (5) 60 min after CPB. RESULTS At baseline, plasma propofol concentrations were similar among the three groups. After the start of CPB, the concentrations of propofol decreased significantly by 41, 35, and 30% of control values in Groups A, B, and C, respectively. In Group A, the concentration of propofol during CPB remained unchanged at less than the concentration before bypass. In Groups B and C, plasma propofol concentrations gradually increased during CPB to the pre-bypass concentrations. In Group A, BSR values did not change significantly during CPB. In Groups B and C, BSR values gradually increased and became significantly greater than baseline values. No patient reported intraoperative awareness. CONCLUSION The pharmacokinetics and pharmacodynamics of propofol change during normothermic CPB. During normothermic CPB, the efficacy of propofol may be enhanced compared with before CPB.

BACKGROUND:Because the time available for cooling and rewarming during deliberate mild hypothermia is limited, studies of the rate of the cooling and rewarming are useful. The decrease in core hypothermia caused by heat redistribution depends on the anaesthetic agent used. We therefore investigated possible differences between sevoflurane and propofol on the decrease and recovery of core temperature during deliberate mild hypothermia for neurosurgery. METHODS:After institutional approval and informed consent, 26 patients were assigned randomly to maintenance of anaesthesia with propofol or sevoflurane. Patients in the propofol group (n=13) received propofol induction followed by a continuous infusion of propofol 3-5 mg kg(-1) h(-1). Patients in the sevoflurane group (n=13) received propofol induction followed by sevoflurane 1-2%. Nitrous oxide and fentanyl were also used for anaesthetic maintenance. After induction of anaesthesia, patients were cooled and tympanic membrane temperature was maintained at 34.5 degrees C. After surgery, patients were actively rewarmed. RESULTS:There was no difference in the rate of decrease and recovery of core temperature between the groups. There was also no difference in skin surface temperature gradient (forearm to fingertip), heart rate and mean arterial blood pressure between the groups. CONCLUSIONS:Sevoflurane-based anaesthesia did not affect cooling and rewarming for deliberate mild hypothermia compared with propofol-based anaesthesia.

BACKGROUND:Dental injuries are the most common reason for complaints against anesthetists. The purpose of this study was to investigate the effect of teeth protector on dental injuries during general anesthesia.METHODS:Incidence of dental injuries was evaluated retrospectively in 5,946 consecutive patients between November 1998 and October 2001. All the patients were interviewed directly at a post-anesthetic clinic.RESULTS:Dental injuries were observed in 2.1% of the patients, and the injuries occurred more frequently in the patients undergoing difficult tracheal intubation. The teeth protector used in the present study was made of cellulose aceto-butylate and was produced using eruko-pressed disks molded from own teeth form. One hundred and eighty five patients (3.1%) requested teeth protectors, and none of them had their teeth injured during anesthesia.CONCLUSION:Our results showed that the teeth protector could protect the teeth from dental injuries and increased the satisfaction with anesthesia. Preoperatively anesthesiologists should know the characteristics of patients' teeth and inform the patients of the risk of injury. We conclude that the custom-made protector might be useful and necessary to preserve the teeth from dental injuries during anesthesia.