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Introduction A retrolaminar block (RLB) is a modified paravertebral technique with a local anesthetic injected at the retrolaminar site. The aim of this non-inferiority, parallel-group, prospective, and randomized study was to compare the analgesic efficacy of the paravertebral block (PVB) and RLB after lung surgery. Methods Eligible subjects were patients aged more than 20 years, with American Society of Anesthesiologists physical status Ⅰ or II, who were scheduled to undergo video-assisted thoracoscopic surgery (VATS) or limited thoracotomy because of lung disease. Patients were randomly allocated to receive either a PVB or RLB using a computer-generated sequence and sealed opaque envelopes. The PVB and RLB were induced by injecting 20 mL of 0.50% ropivacaine and 40 mL 0.25% ropivacaine, respectively. As the primary outcome variable, we considered the area under the curve (AUC) of the postoperative pain intensity using the trapezoidal method. Pain intensity was assessed using an 11-point numerical rating scale (NRS). We converted the NRS (0-10) into the visual analog scale (VAS) (0-100 mm) proportionally. We compared the AUC of the converted NRS (AUC-cNRS) on coughing between one and two hours after the operation. The non-inferiority margin was set at 25 mm × h in the AUC-cNRS. Patients and nurses were blinded to group assignments. Secondary outcomes included time to perform the block, NRS for pain intensity at rest and on coughing at one, two, four, 24, and 48 hours after the operation, the incidence of postoperative nausea and vomiting, time to first morphine use after the operation, and cumulative morphine consumption at 24 and 48 hours after the operation. Results In each group, 25 patients were randomized and analyzed. No significant difference in the AUC-cNRS was noted between the groups (P = 0.117). The mean difference in the AUC-cNRS (group RLB minus group PVB) was 13.42 mm × h, 95% confidence interval, -3.48 to 30.32 mm × h. However, when patients with unexpectedly extended skin incision were excluded from the analysis, the AUC-cNRS of group RLB was significantly higher as compared to group PVB (P = 0.0388). The time to perform the block was longer in PVB as compared to the RLB group (P < 0.0001). No significant differences were noted in the remaining secondary outcomes. Conclusion The non-inferiority of RLB as compared to PVB was not confirmed. Though RLB has the advantage of a shorter time to perform, RLB is not recommended for patients undergoing VATS or limited thoracotomy because of lack of efficacy as compared to PVB.

We report a case of an 18-year-old man with Noonan syndrome, severe hypertrophic obstructive cardiomy- opathy and right ventricular outflow tract obstruction who underwent septal myectomy under general anes- thesia. In our case, the ventricular outflow tract pres- sure gradients were 108 mmHg at left and 79 mmHg at right. General anesthesia was induced deliberately by fentanyl, midazolam and sevoflurane. Anesthesia was maintained with sevoflurane. For treatment of hypotension, we performed volume loading and admin- istration of phenylephrine. We did not use drugs that increase heart rate or contractility. Preload and after- load were well maintained, and the operation and gen- eral anesthesia were completed without serious prob- lem.

Pheochromocytoma is complicated with catecholamine cardiomyopathy, and preoperative care becomes considerably more difficult We report anesthetic management for an 48-year-old man brought to our hospital by ambulance and immediately hospitalized due to pheochromocytoma crisis complicated with catechol- amine cardiomyopathy presenting inverted-takotsubo pattern asynergy. Before surgery, α and β blocking drugs were used to control hypertension and tachycardia, and continuous hemodiafiltration was initiated and the patient was intubated for severe pulmonary edema. Seven days later, he underwent laparoscopic adrenalectomy. Total intravenous anesthesia was achieved with propofol, remifentanil, fentanyl, and rocuronium. During the operation, continuous infusion of landiolol, phentolamine, and nitroglycerin, and addi- tional bolus injections of landiolol were given to control hypertension. After severing the right adrenal vein, noradrenaline (0.15 μg · kg⁻¹ · min⁻¹), and dopamine (4μg · kg⁻¹ · min⁻¹) were started and the patient was placed in the intensive care unit Inverted-takotsubo pattern asynergy is not very common, and treatment consists of supportive care, as in the usual takotsubo. Preoperative CHDF (continuous hemodiafiltration) may be useful when it is difficult to control hypertension or tachycardia with medications.

A sixteen-year-old female patient with congenital aortic stenosis underwent Ross procedure. We monitored bilateral regional cerebral saturation of oxygen (rcSO₂) on the forehead at the right and left of the midline. After aortic and bicavel cannulation, cardiopulmonary bypass was instituted. On the mor- row of aortic cross clamping, the rcSO₂ fell from approximately 55% to below 30%. We searched the cause of this phenomenon, and detected that the tip of aortic cannula was inserted to the left subclavian artery. After repositioning, the bilateral rcSO₂ increased to above 65%. We felt keenly that the monitoring of rcSO₂ is useful to recognize corrective adjustment of the cannula ori- entation, and the avoidance of cerebral hypoperfusion during the cardiopulmonary bypass period.

A 25-year-old woman with unrepaired pulmonary atresia, ventricular septal defect and major aorto-pul- monary collateral artery was scheduled for single- staged definitive repair. She was complicated with mod- erate pulmonary hypertension, and had 2 MAPCAs arising from the descending artery. Cardiac catheter- ization demonstrated that right ventricular pressures were approximately equal to the left ventricular pres- sure. Pre-bypass, we maintained her PVR not too high in order to maintain her pulmonary blood flow. Post- bypass, we used hemodynamic support with dopamine, olprinone and nitroglycerin, maintaining her PVR opti- mally low. We inserted a catheter introducer in her jugular vein to deal with massive hemorrhage. After the repair, her right ventricular pressures were 7/10 of systemic pressure, and her postoperative course was uneventful.

To elucidate cortical mechanisms underlying point localization of a pain spot, we investigated event-related potentials (ERPs) while using a CO2 laser beam to apply a pain stimulus to the hand dorsum in 16 healthy men. The stimulus spot (pain spot) was shifted for each stimulus, while the subject was requested to identify the stimulated spot as accurately as possible and to use a pointer in the non-stimulated hand to indicate the corresponding spot on a figure of a hand that was projected onto a screen (localization condition). For the control condition, the subject pointed to a single predetermined spot, regardless of the location of the stimulation (control motor task condition). Electroencephalograms were recorded from 21 electrodes, referenced to the linked earlobes, and were averaged time-locked to the stimulus onset for each task separately. Under the control rest condition (neither point localization nor motor task), only two early components (N2 and P2) were recorded. During the control motor task condition (no point localization), in addition to N2 and P2, a steep negative-going slope was recorded at the fronto-central region. Exclusively during the localization condition, a positive peak (647 ms, 5.6 microV for the left and 634 ms, 5.7 microV for the right hand stimulation) was identified; this was maximal at the midline centro-parietal area and distributed symmetrically over the scalp. It is suggested that the late positive component detected exclusively during the localization task is related to the somatotopic point localization of the pain spot. From the distribution of this ERP, the task most likely involves bilateral activation of the superior parietal cortices.

A morphological filter was designed for extracting the waveform characteristics of pain SEP from the single-sweep record. The properties of the basic operations for the morphological filter; erosion, dilation, opening and closing were clarified in order to design an appropriate filter. The morphological filter was designed by selecting the structuring elements, which represented the features of the pain SEP waveform. The designed morphological filter was evaluated using the simulation data, and applied to the pain SEP data obtained from a normal adult with satisfactory results.

In 6 patients with Wallenberg's syndrome who showed a dissociated loss of pain sense, we recorded pain-related somatosensory evoked potentials following CO2 laser stimulation of the hand dorsum (pain SEPs). Two components, N2 and P2, were recorded by stimulation of the unaffected hand, whereas on the affected side they were absent or decreased in proportion to the severity of hypalgesia which was evaluated by both needle test and CO2 laser stimulation. Latency of either component, if appeared, was longer in the affected hand stimulation than that in the unaffected one. In contrast, N20 of the conventional electrically-stimulated SEPs (electric SEPs) showed no difference between the two sides. It is concluded that, unlike other electrophysiological methods, pain SEPs following CO2 laser stimulation can quantitatively evaluate functional impairment of the spinothalamic tract in Wallenberg's syndrome.

Although acupuncture has a long history of analgesic effects, the mechanisms underlying its effects are still unclear. Somatosensory evoked potential (SEP) methodology has been adopted in the research of acupuncture since the 1970s. In research on the effects of acupuncture on the conventional SEP, variable results have been observed, and two different opinions concerning the presence or absence of acupuncture effects on the conventional SEP are discussed. Since the conventional SEP is mediated mainly by fast conducting sensory nerve fibers, the conventional SEP methodology, especially that for recording short-latency SEP, may be inadequate for studying acupuncture mechanisms. In the case of the long-latency cortical SEP, there are too few data available to judge the effects of acupuncture analgesia (AA). Studies on the effects of AA on pain SEPs demonstrated that AA has a suppressive effect on amplitude of the pain SEP (and affecting the latency as well in some experiments) in both animals and humans, being accompanied by increased pain threshold. Thus, acupuncture seems to have analgesic effects that are probably related to activation of the antinociceptive system, and application of the pain SEP methodology to the study of mechanisms of AA may be promising.

There is currently accumulating evidence for bidirectional communication between the neuroendocrine and immune systems. Various cytokines have been suggested to be involved in the stimulation of stress hormone secretion during the times of infection and inflammation. To assess the possible involvement and pathophysiologic significance of cytokines in the mechanisms responsible for the perioperative stress response of the hypothalamo-pituitary-adrenal axis, we observed the changes of plasma adrenocorticotropic hormone and cortisol levels together with those of plasma endotoxin and cytokine levels. In patients undergoing pancreatoduodenectomy, perioperative stimulation of adrenocorticotropic hormone and cortisol secretion was accompanied by a significant elevation of plasma cytokine levels. Application of epidural block up to the upper thoracic levels failed to suppress this stress response effectively. In patients undergoing unilateral total hip replacement, the response of plasma hormone levels was smaller and briefer with no significant increase of plasma cytokine levels. Application of epidural block up to the lower thoracic levels suppressed this hormonal response almost completely. In patients undergoing pancreatoduodenectomy, a significant elevation of plasma endotoxin level was followed by a gradual but significant elevation of plasma tumor necrosis factor alpha and interleukin-6 levels. It seems likely that the stimulatory effects of these cytokines on the secretion of adrenocorticotropic hormone and cortisol might be involved in the development of the greater and more prolonged stress response of hypothalamo-pituitary-adrenal axis. Our present study suggests that not only neural input from the surgical wound but also stimulation of cytokine production were responsible for the development of the stress response of the hypothalamo-pituitary-adrenal axis during and after upper abdominal surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolates from various clinical materials in 13 hospitals in Akita prefecture and their drug susceptibility were investigated by the Chemotherapy Research Committee of Akita Prefecture during the period from Dec., 1987 to Feb., 1988. The results were as follows: 1. The total number of isolates was 8,387, including Staphylococcus aureus (18.9%), Pseudomonas aeruginosa (10.9%), Staphylococcus epidermidis (7.3%) and Enterococcus faecalis (6.6%). S, aureus and P. aeruginosa were detected more frequently in the larger hospitals. 2. The detection frequency of S. aureus from the sputum, throat swab and pus exudate was also very high. There was a diversity in isolates from the urine and the frequency of Escherichia coli was low. More than half of the isolates from the blood were S. epidermidis and S. aureus. Many kinds of bacteria were detected from pleural fluid and ascites, but the isolate showed no particular tendency. 3. The susceptibility of S. aureus to oxacillin were variable in hospitals, and the susceptibility to cefazolin were even lower. Low susceptibility were also seen with norfloxacin. S. aureus showed the highest susceptibility to minocycline. The susceptibility was lower for inpatients than for outpatients. P. aeruginosa showed low susceptibility to cefsulodin. The number of ampicillin-resistant Haemophilus influenzae isolates tended to decrease. Enterobacter cloacae showed a low susceptibility for cephems. Serratia marcescens showed low susceptibility to many drugs. Based on the above results, we concluded that attention should be paid to S. aureus, P. aeruginosa and Enterobacter in clinical practice.

We recorded cortical potentials evoked by painful CO 2 laser stimulation (pain SEP), employing an oddball paradigm in an effort to demonstrate event-related potentials (ERP) associated with pain. In 12 healthy subjects, frequent (standard) pain stimuli (probability 0.8) were delivered to one side of the dorsum of the left hand while rare (target) pain stimuli (probability 0.2) were delivered to the other side of the same hand. Subjects were instructed to perform either a mental count or button press in response to the target stimuli. Two early components (N2 and P2) of the pain SEP demonstrated a Cz maximal distribution, and showed no difference in latency, amplitude or scalp topography between the oddball conditions or between response tasks. In addition, another positive component (P3) following the P2 was recorded maximally at Pz only in response to the target stimuli with a peak latency of 593 msec for the count task and 560 msec for the button press task. Its scalp topography was the same as that for electric and auditory P3. The longer latency of pain P3 can be explained not only by its slower impulse conduction but also by the effects of task difficulty in the oddball paradigm employing the pain stimulus compared with electric and auditory stimulus paradigms. It is concluded that the P3 for the pain modality is mainly related to a cognitive process and corresponds to the P3 of electric and auditory evoked responses, whereas both N2 and P2 are mainly pain-related components.

In order to clarify the generator mechanism of pain-related evoked potentials (pain EPs), we studied the scalp topography of the pain EPs following CO2 laser stimulation of hand dorsum by using balanced sternovertebral electrodes as the noncephalic reference in 11 normal volunteers. We also examined the effects of predictive warning signal (light-emitting diode) on the pain EPs. In both the warned and unwarned conditions, all of the 22 hand stimulations showed a large negative component (N2) at the peak latency of about 213 ms followed by a large positive component (P2) at the peak latency of about 329 ms. A preceding small negative component (N1) at the peak latency of about 148 ms was detected in 12 of the 22 hand stimulations in the warned condition and in 13 of the 22 hand stimulations in the unwarned condition. P2 was significantly larger and occurred earlier in the warned condition than in the unwarned condition, whereas other components did not differ between the two conditions, suggesting that an increased attention of the subject to the stimulus influenced the generator mechanism of the P2 component. With regards to the scalp topography, N2 was maximal at Cz and widespread transversely to both sides, whereas P2 was maximal at Cz or Pz and spread more posteriorly than N2. These findings suggest that P2 is generated by a different mechanism from N2 and is most likely associated with pain-related cognitive function. N1 was localized to the contralateral central and midtemporal areas, confirming that the nociceptive inputs are perceived in the sensory cortex in humans. The question as to whether the N1 component is generated in the hand area of the primary somatosensory cortex or in the secondary somatosensory cortex, or in both areas, remains to be solved.

It is well known that surgical invasion activates the hypothalamo-pituitary-adrenal (H-P-A) axis and induces marked elevation in plasma adrenocorticotropic hormone (ACTH) and Cortisol levels during and after surgery. The stress response of plasma ACTH and Cortisol levels cannot be totally suppressed by epidural [1] or subarachnoid anesthesia [2], especially in upper abdominal surgery [3], which suggests the involvement of some factor(s) other than afferent neural output arising from the injury site [4]. Some cytokines have recently been suspected to play important roles in the activation of the H-P-A axis at the times of infectious challenge and other stressful conditions [5–7]. To assess the possible involvement and role of cytokines in the stress response of the H-P-A axis during surgical procedures, we observed changes in the levels of plasma ACTH, Cortisol, endotoxin, tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6) in patients undergoing upper abdominal surgery. We then investigated the ACTH-releasing activities of these cytokines using an in vivo experimental system.

We have studied the effects of flumazenil on sleep time and EEG in rats anaesthetized with 1.5% halothane, propofoi 20 mg kg−1, thiamylal 30 mg kg−1, or combinations of diazepam 5 mg kg−1 and anaesthetic agents. We also studied the effects of flumazenil 0.3, 3 and 30 mg kg−1 on behaviour and EEG. Flumazenil 0.3 and 3 mg kg−1 alone had no effect on behaviour or EEG, but flumazenil 30 mg kg−1 had depressive effects similar to those of diazepam on behaviour and EEG. Flumazenil 0.3, 3 and 30 mg kg−1 i.v., antagonized the effects of diazepam 10 mg kg−1 i.v. on behaviour and EEG. Flumazenil had no antagonistic effect on sleep time induced by anaesthetic agents, but flumazenil 30 mg kg−1 potentiated propofol-induced anaesthesia. Flumazenil did not affect anaesthesia-induced EEG changes. Diazepam 5 mg kg−1 potentiated anaesthesia. Flumazenil antagonism of diazepam potentiation varied with anaesthetic agent: flumazenil 0.3 mg kg−1 antagonized diazepam action in halothane anaesthesia, but 30 mg kg−1 was required in propofoi anaesthesia; this large dose was insufficient in thiamylal anaesthesia.

To elucidate whether interleukins are involved in vasopressin or oxytocin release during cytokine-related stressful conditions, we examined the effects of human interleukin-1 beta and interleukin-6 on plasma vasopressin and oxytocin levels in rats. Interleukin-1 beta administrated intravenously stimulated both the vasopressin and oxytocin secretion in dose-dependent manners. Neither hormone release was observed following interleukin-6 administration. Pretreatment with aspirin significantly attenuated the effects of interleukin-1 beta on both the vasopressin and oxytocin levels. SC-19220, a prostaglandin E2 receptor antagonist, did not affect the interleukin-1 beta-induced increase of plasma oxytocin levels, but almost completely abolished its effect on plasma vasopressin levels. These results suggest that under certain stressful conditions which accompany the stimulation of cytokine production, interleukin-1 is involved in the increase of plasma vasopressin and oxytocin levels and, moreover, different kinds of prostaglandins are suggested to participate in these interleukin-1-induced hormone release.

頸椎前方固定術308例の麻酔を経験し, 麻酔管理上の問題点について考察した. マイクロサージェリーであり, 術中の体動を避けるために全例筋弛緩薬を用いた全身麻酔で管理した. 挿管操作による頸髄損傷を避けるため,術前に安全な頸部の可動域を調べ, 原則として筋弛緩下に注意深く気管内挿管を行った. 循環系の不安定な症例が多いこと, 大出血の可能性があることを考え、循環系の抑制の少ないドロペリドール, ジアゼパムに調節性に富む吸入麻酔薬を低濃度で併用した. 術後は呼吸麻痺や上気道閉塞の恐れがあるため, 特に呼吸状態の観察が重要であり, 覚醒時に不穏状態にならず, 術後の呼吸抑制の少ない麻酔がよい.

Anemia-inducing substances were extracted from gastric juice of patients with gastric cancer and from human placenta. The immunological relationship of these substances was tested by the gel diffusion technique of Ouchterlony. The results were summarized as follows: 1) A rabbit was immunized with an anemia-inducing substance from the placenta (P-62) using Freund's adjuvant. The antiserum prepared was tested for the presence of antibodies against P-62 by complement fixation test. The test showed a high titer of 1:512. The antiserum was designated as P-62•Ab. 2) Analyses by Ouchterlony's method showed that P-62•Ab reacted markedly with P-62 and with an anemia-inducing substance from gastric juice (K-8) of patients with gastric cancer. But the corresponding fraction from normal gastric juice did not show the reaction with P-62•Ab. 3) These results indicated that there was a common antigenicity between anemia-inducing substances in the cancerous gastric juice (K-8) and in the human placenta (P-62).

Anemia-inducing substances have been prepared from gastric juice (K-7 and K-8) of patients with gastric cancer, cancerous gastric tissue (MK-62 and MK-63) and human placenta (P-62) by means of ethanol or acetone fractionation, and the effect of these substances on the osmotic fragility of rabbit red cells in vitro was studied. These substances, which are mucoproteins, decreased the osmotic resistance of the rabbit red blood cells in vitro.

Factors affecting early v late weaning from ventilatory support after cardiac surgery were retrospectively compared in 15 patients with cardiac cachexia. These patients were divided into two groups based on the duration of postoperative ventilatory support, group I (n = 7) less than two days (22 +/- 8 hours) and group II (n = 8) over three days (140 +/- 125 hours). Findings in 14 randomly selected patients without cardiac cachexia who underwent cardiac valve replacement were also examined. Comparisons were made between the groups in regards to the following parameters: (1) preoperatively: anthropometric, biochemical, and immunologic parameters of nutritional status, hepatic function, cardiothoracic ratio (CTR) on chest x-ray, and data from cardiac catheterization; (2) intraoperatively and postoperatively: anesthetic drugs, duration of surgery, cardiopulmonary bypass (CPB), aortic cross-clamp, and postoperative use of inotropes. The anthropometric measurements, cell-mediated immunity, and hepatic function were significantly decreased in all patients with cachexia, but with no significant differences between the groups. Serum transferrin levels, which increased in patients with cachexia, showed no significant difference between the groups. The levels of serum albumin were significantly lower in cachectic patients than in patients without cachexia; they were significantly higher in group II than in group I. The durations of surgery and CPB were significantly longer in group II, but there was no significant difference in the duration of aortic clamping between the groups. The postoperative use of inotropes was higher in group II. These results indicate that group II patients were nutritionally as well sustained as group I. However, they had less satisfactory cardiac function, and therefore required a longer duration of postoperative ventilatory support.