Comparison of 0.2% Ropivacaine and 0.25% Bupivacaine in Pediatric Caudal Block : Evaluation of Postoperative Pain and Plasma Concentration of Local Anesthetics

The purpose of this study is to assess the effects of pediatric caudal block using 0.2% ropivacaine or 0.25% bupivacaine on intraoperative and postoperative analgesia. We also examined plasma concentrations of the local anesthetics after caudal injection. Forty children, who were scheduled for inguinal herniorrhaphy, underwent caudal block with 0.2% ropivacaine 1 ml/kg (group R, n=20) or 0.25% bupivacaine 1 ml/kg (group B, n=20) after induction of general anesthesia. Anesthesia was maintained using a face mask with 66% nitrous oxide in oxygen supplemented with sevoflurane. Postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured using gas chromatography. Since two patients in Group R and one patient in Group B required more than 1 % of sevoflurane to prevent their body movement when the surgical procedure was started, they were excluded from this study as the failed block. No patient in Groups R and B required intraoperative analgesics under light general anesthesia and postoperative analgesics. The maximum plasma concentration of ropivacaine and bupivacaine were 0.70±0.28μg/ml at 45 min and 0.80±0.42μg/ml at 30 min after the caudal injection, respectively. In conclusion, pediatric caudal block with 0.2 % ropivacaine is an alternative to 0.25 % bupivacaine for intraoperative and postoperative analgesia

Comparison of Remifentanil and Landiolol on Hemodynamic and Plasma Catecholamine Responses to Tracheal Intubation

The purpose of this study is to compare remifentanil with landiolol to examine the effects of hemodynamic and plasma catecholamine responses to tracheal intubation. Sixty patients scheduled for elective surgery were randomly divided into three groups, to receive either normal saline( group C), a 1-minute loading infusion of remifentanil 0.5 m g/kg followed by an infusion of remifentanil 0.25/m g/kg/min during the study(group R), or a 1-minute loading infusion of landiolol 0.125 mg/kg followed by an infusion of landiolol0.04 mg/kg/min during the study (group L). After the 1-minute loading infusion of each drug, anesthesia was induced with intravenous injection of propofol 2 mg/kg, and vecuronium 0.1 mg/kg. Five minutes after the administration of each drug, tracheal intubation was performed within 30 seconds. Mean arterial pressure remained below the baseline value after tracheal intubation in group R, but not in groups L and C.Heart rate significantly increased after tracheal intubation in group C, but not in groups R and L. Plasma concentration of adrenaline remained below the baseline value after tracheal intubation in all groups, but it was significantly lower in group R, compared with other groups. Plasma concentration of noradrenaline significantlyincreased after tracheal intubation in groups L and C, but not in group R. Bispectral index in group R remained lower than that in groups L and C after tracheal intubation. Remifentanil may be preferableto landiolol to provide cardiovascular stability after tracheal intubation

Effects of Neostigmine and Sugammadex on QT Interval and QT Dispersion

Dispersion of QT dispersion(QTD)in 12-lead electrocardiogram is a useful index for assessment of ventricular arrhythmia risk and cardiovascular event. To determine the effects of reversal of nondepolarizing neuromuscular blockade on cardiovascular event, we evaluated the QT interval QTD after reversal of the neuromuscular blockade by neostigmine or sugammadex.After obtaining the approval of the ethics committee of Dokkyo Medical University Hospital, 40 patients with ASA physical status I or II were allocated to following two groups. Patients in the groups N(n=16)and S(n=15)received combination of neostigmine(40?μg/kg)and atropine(20?μg/kg)or sugammadex(2?mg/kg)as a reversal of neuromuscular blockade after the operation under 1% sevoflurane anesthesia, respectively. The RR interval, QT interval(QT), corrected QT interval(QTc), QT dispersion and corrected QT dispersion(QTcD)were consecutively recorded using computerized measurement before and after administration of reversal agents in both groups.RR interval in the group N significantly decreased 1-4?min after reversal of the neuromuscular blockade, but not in the group S. However, in the groups N and S, QT interval, QTc interval, QTD and QTcD were not changed after reversal of the neuromuscular blockade. Moreover, there was no significant difference between both groups in QT interval, QTc interval, QTD and QTcD during the study.Our results suggest that neither neostigmine nor sugammadex may increase the risk of ventricular arrhythmia and cardiovascular events in reversal of the neuromuscular blockade under sevoflurane anesthesia

Airway Obstruction due to Hematoma Following Internal Jugular vein Cannulation

A patient developed neck swelling and acute airway obstruction following an internal jugular vein cannulation. During laryngoscopy, glottic exposure was impossible because of a hematoma-induced anatomical distortion of standard laryngeal landmarks. Finally, a nasotracheal tube was intubated into the trachea fibreoptically. This life-threatening complication is rare, possible origin and mechanism for the sudden hematoma are discussed, as well as the airway management

NMDA Component of the Excitatory Synaptic Transmission of Neurons Containing Serotonin or GABA in the Ventrolateral Subdivision of the Periaqueductal Gray Matter of Mouse

The midbrain periaqueductal gray( PAG) plays a crucial role in the descending pain modulating system.NMDA receptors (NMDARs) and serotonergic and GABAergic neurons have been identified in the PAG and are involved in the descending pain-modulating pathway. We characterized the NMDA component of the excitatory synaptic transmission within the ventrolateral subdivision of the PAG( vlPAG) using a whole cell patch clamp technique and then detected the expression of tryptophan hydroxylase (TPH), serotonin synthesizing enzyme, and glutamate decarboxylase (GAD), GABA synthesizing enzyme to understand thevlPAG intrinsic neurotransmission. The NMDA/non-NMDA ratio and the decay time constant of theNMDA component of the non-serotonergic GABAergic neurons were significantly larger than those of nonserotonergicnon-GABAergic neurons and serotonergic GABAergic neurons. This suggests that the non-serotonergic GABAergic neurons might play an important role in the descending pain modulating system originated from the PAG. The decay time constant of the NMDA component of the non-serotonergic non-GABAergic neuron was significantly greater in the mouse with partial sciatic nerve ligation compared with the control mouse. These results suggest that the subunit composition of the NMDAR in the non-serotonergicnon-GABAergic neurons change during neuropathic pain

ザッシュ セイケン ニ オケル ワンシンケイソウ ブロック ガ ジョウシ ケツリュウ リョウ ニ オヨボ ス エイキョウ ニ ツ イテ

雑種成犬の腕神経叢ブロック(BPB)モデルを作製し,ブロック後の上肢血流量の変化について調べた.【方法】雑種雄性成犬を対象とし,全身麻酔下にBPB モデルを作製し,生理食塩水1 mL(生理食塩水群:8 例)と1%メピバカイン1 mL(局所麻酔薬群:8 例)投与後の正中動脈血流量(MABF)の変化を記録,比較検討した.BPB は,超音波下に21 ゲージ針を腕神経叢内に進め,電気刺激装置にて刺激を確認しながら薬液を注入し,測定終了時に頚部を開創してインジゴカルミン含有の薬液の神経叢内に限局した広がり確認した.BPB による上肢血流量の変化は超音波血流計を用いてMABF を測定することにより評価した.【結果】局所麻酔薬群では,薬液注入30 分後よりブロック側のMABF が有意に増加し,その増加は60 分後に最大値(136.7±35.3%)に達し,有意な血流増加は140 分後まで持続した.局所麻酔薬群のブロック反対側のMABF の変動は認められなかった.一方,生理食塩水群では,薬液注入後のMABF の変動は,ブロック側,反対側ともに認められなかった.【結語】雑種成犬のBPB を作製し,交感神経遮断によると考えられる上肢の動脈血流増加作用を確認した.The purpose of this study is to establish a model of brachial plexus block( BPB) in anesthetized dogs and evaluate changes in the arterial blood flow after BPB. Sixteen anesthetized dogs were enrolled into this study and divided into two groups as follows;M group( 1% mepivacaine 1 mL:n=8) and C group (physiological saline solution (PSS)1 mL:n=8). For BPB, a block needle was inserted into the left brachial plexus under ultrasonic imaging, the brachial plexus was identified using a nerve stimulator and the spread of drug solutions was confirmed by indigo carmine under dissection after the study. Changes in the arterial blood flow were evaluated by the median arterial blood flow (MABF) using the ultrasonic blood flowmeter. In group M,left MABF was significantly increased from 30 min to 120 min after BPB, and maximum increase in MABF was 136.7±35 % at 60 min after BPB. In group C, changes in left MABF were not observed during the study. In both groups, right MABF was not changed after BPB. Our results suggest that BPB may have a vasodilating effect induced by sympathetic block

ドッキョウ イカ ダイガク デ ハジメテ ノ ノウシ カラノ ゾウキ テキシュツ ジュツ ノ マスイ ケイケン

獨協医科大学で初めての脳死下臓器摘出術の麻酔を経験した.ドナーは50歳代の女性で,くも膜下出血による脳死であり,麻酔および摘出術は特に問題なく終了した.臓器摘出術の麻酔管理の主な要点は,各摘出臓器の機能を最大限に維持するための適切な循環および呼吸管理である.本症例におけるわれわれの経験は近い将来,獨協医科大学で行われるであろう臓器摘出術及び移植術の麻酔管理に有益な情報になると考えられた.We report the anesthetic management of the first case ofthe brain death for organ donation in Dokkyo Medical University.The donor was brain death after subarachnoidhemorrhage. Anesthesia and surgical procedure were doneuneventfully. The aims of anesthetic management are tomaintain optimal organ perfusion. We believe that this firstexperience will be helpful for the anesthetic management ofthe organ transplantation patient in the future of DokkyoMedical University

シンケイ ショウガイ ゴ ノ セキズイ コウカク ニ オケル シナプス デンタツ ノ ヘンカ マクデンイ イメージング ホウ オ モチイテ

末梢神経が障害されると脊髄後角の神経回路網の再構築が起こり,興奮性および抑制性シナプス伝達の変化が生じると考えられている.本研究では,高速イメージングシステムを用いた膜電位変化の観察により,末梢神経障害が脊髄後角表層内の興奮性シナプス伝達に与える影響を検討した.膜電位感受性色素で染色したマウス脊髄スライス標本の高速蛍光測定を行い,脊髄後根流入部の電気刺激で得られる脊髄後角表層の膜電位変化を観察した.さらに,CNQXおよびAPV灌流下の変化について調べた.そして,これらの変化における坐骨神経部分結紮による影響についても調べた.脊髄後根流入部の電気刺激で得られる脊髄後角表層の膜電位変化は,CNQXの灌流によって減弱し,APVの灌流でさらに減弱したが完全には消失しなかった.この現象は,坐骨神経部分結紮を施したマウスでより顕著にみられた.NMDA受容体とAMPA受容体を介する興奮性シナプス伝達が坐骨神経部分結紮によって増大することを高速蛍光測定法で確認した.神経障害によってNMDA受容体とAMPA受容体以外の興奮性シナプス伝達が亢進している可能性が示唆された.The effect of spinal synaptic change on development of neuropathic pain remains unclear. To determine the effect of sciatic nerve ligation on excitatory synaptic transmission in the spinal dorsal horn, we observed the optical images of fluorescent changes induced by electrical stimulation using voltage-sensitive dye. The sciatic nerve partial ligation was performed in 6 to 8 weeks male ICR mice, according to Seltzer\u27s method under halothane anesthesia. The spinal slices were prepared one week after ligation, and incubated for 20 min with a di-4-ANEPPS to use optical imaging. After rinsing, the slices were placed into the recording chamber on the microscope stage and perfused by Krebs\u27 solution. Fluorescent changes of di-4-ANEPPS in the spinal dorsal horn were measured using MiCAM02. During the observation, bicuculline, strychnine, CNQX and APV were perfused. The fluorescent changes in the dorsal horn were reduced by perfusion of CNQX and APV. The fluorescent changes were predominant in ligated mice compared to control mice. The blockade of CNQX and APV on excitatory synaptic transmissions was incomplete. These results suggested the implication of excitatory synaptic transmission except AMPA or NMDA were suspected

チョウオンパ ガイド カ センコツ コウマク ガイ ブロック : センコツ トノ カイボウガク テキ ケントウ

仙骨硬膜外ブロックは外科手術の麻酔あるいは慢性疼痛の除痛手段に対して用いられる.従来のランドマーク法による仙骨硬膜外ブロックは小児では容易で安全であるとされているが,成人では70〜80%の成功率とされている.本研究では超音波ガイド下仙骨硬膜外ブロックを成人患者50症例で施行してその有用性を検討した.結果は全症例にてブロックは成功した.さらに超音波ガイド下仙骨硬膜外ブロックの成功率と安全性をより高くするために仙骨裂孔(仙骨角)の形態変異を観察し,得られた超音波画像の関係を検討した.Caudal epidural block is often used in patients for anesthesiaand chronic pain. Caudal epidural block with surfacelandmark guidance has been generally considered simpleand safe to perform especially in child patients. However,the success rate of the block in adults has been 70-80 % inthe literature. This study was aimed to determine the clinicalefficacy of caudal epidural block using ultrasound in 50patients. All the blocks were performed successfully. In addition,to increase both success rate and safety of ultrasoundguided caudal block, an anatomical study of thesacral hiatus( sacral cornu) has been performed to demonstratethe type and frequency of the shape variations tocompare with ultrasound imagings

ナイ ジカク ニ タイ スル リュウサン アルミニウム ・ タンニン サン チュウシャ エキ ( ALTA ) リョウホウ シコウ 5 カゲツゴ ニ ショウジ タ コウモン カン ・ チョクチョウ ネンマク ヘンセイ ノ 1 レイ : ALTA シコウ ゴ ノ ネンマク ヘンセイ

症例60歳女性,10年来の脱出性内痔核の治療として2014.2.12硫酸アルミニウムカリウム・タンニン酸注射液(Aluminium Potassium Sulfate Tannic Acid:以下ALTA)を使用した四段階注射痔核硬化療法を受けた.経過良好であったが,7月中旬よりの肛門痛・発熱にて入院,触診のみでボロボロ崩れ落ちてゆく5時方向を中心とした約1/4周を占める広範な肛門管・直腸粘膜変性壊死を認めデブリードマン施行.疼痛・発熱は持続したが,禁食,抗生物質・解熱剤の投与,2回の追加デブリードマンにて,変性壊死部位は脱落し潰瘍と変化し,一か月後軽快退院した.非常に稀な経過と考えられたため報告した.Recently, the number of the Aluminum Potassium Sulfate and Tannic Acid(ALTA)injections therapy for internal hemorrhoids have been increasing markedly in Japan because of its minimal invasive therapy, quick response and acceptable recurrence rate. However, there are some reports of adverse reactions and side effects after ALTA such as Fournier\u27s Gangrene, rectovaginal fistula and rectal ulcer. We experienced a case of anorectal mucosal degeneration and necrosis after five months ALTA injection for internal hemorrhoids. A 60 year-old female was treated with sclerosing therapy with ALTA injection for grade II～III internal hemorrhoids according to the Gligher classification. Although the patient was in good course in 5 months after therapy, she developed a high fever and anal pain. Antibiotics were administrated, but remission was not achieved. Three times debridements were performed under local and intravenous anesthesia with a diagnosis of anorectal mucosal degeneration and necrosis. After approximately a month admission in the hospital was necessary for the treatment of the anorectal ulcer after debridements, she has been free from fever, pain and hemorrhoids