南 浩一郎

A 9-year-old boy was scheduled for excision of tracheal granuloma which had developed at the tip of a tracheostomy tube. Instead of a tracheostomy tube, a 4 mm ID tracheal tube was inserted via the tracheostomy beyond the tracheal constriction because of rapid development of respiratory failure. General anesthesia was induced and maintained with sevoflurane and oxygen via the tube, and a size 2.5 laryngeal mask airway (LMA) was inserted without muscle relaxant. Spontaneous respiration remained. Under monitoring by fiberoptic tracheoscopy via the LMA, the tracheal tube was extubated carefully. An 8 Fr. suction tube was indwelled via the tracheostomy beyond the stenosis for oxygen supply. After sealing the tracheostomy, he could breath spontaneously through the LMA. During the excision of tracheal granuloma by holmium:YAG laser, fiberoptic observation was continued via the LMA, and the procedure was performed without any complication. We conclude that the tracheal stenosis can be managed using the LMA, continuous fiberoptic monitoring and additional option of keeping spontaneous ventilation.

A 71-year-old man was scheduled for an extirpation of chronic expanding hematoma (CEH) of his right thorax. He had a history of right thoracoplasty for tuberculosis 37 years previously. He complained of dyspnea that had deteriorated over three months. His inflammatory responses including general fatigue and fever due to chronic empyema remained to be resolved. The chest computed tomography revealed that the CEH remarkably compressed the trachea and the heart resulting in the cause of left mediastinal deviation. General anesthesia was induced with fentanyl and propofol, and maintained with sevoflurane. During general anesthesia, mean central venous pressure (CVP) via the right femoral vein and arterial blood pressure (ABP) via the left radial artery were monitored. Bilateral peripheral vein catheters with 16 G could effectively provide huge amount of transfusion. Although his blood loss was 10,000 ml because of superior vena caval rupture and oozing from pleura, prompt and adequate management of hemodynamics could be maintained using CVP and ABP monitoring. The CEH is known as a specific type of chronic empyema and its extraction would require ingenuity since there are number of factors associated with diagnosis, indication and prevention. Each case is to be evaluated individually and managed carefully.

There have been several reports on anesthesia for a patient with a history of multiple drug allergies. We present here anesthesia for a 33-year-old woman with histories of multiple drug allergies. She was scheduled to undergo total abdominal hysterectomy. We could not perform preoperative screening of the drugs using a dermal test because of a high risk of anaphylactic shock. Anesthesia was induced and maintained with sevoflurane and nitric oxide. The operation was finished without complications and her postoperative course was uneventful. It is important preoperatively to obtain histories of allergies adequately for recognition of allergens.

A forskolin derivative, colforsin daropate hydrochloride (CDH), acts directly on adenylate cyclase to increase the intracellular cyclic adenosine monophosphate levels which produce a positive inotropic effect and a lower blood pressure. However, little is known about the effects of CDH on the renal function. We used laser Doppler flowmetry to measure the cortical renal blood flow (RBF) in male Wistar rats given a continuous intravenous infusion of CDH and evaluated the effects of CDH on the noradrenaline (NA) and angiotensin II (AngII) induced increases in blood pressure and reductions in RBF. Continuous intravenous administration of CDH at 0.25 microg/kg/min did not affect the mean arterial pressure (MAP), but increased heart rate and RBF. Continuous intravenous administration of CDH at high doses (0.5-0.75 microg/kg/min) decreased the MAP, with little effect on the RBF. The administration of exogenous NA (1.7 microg/kg) increased the MAP and decreased the RBF. However, a bolus injection of NA did not decrease the RBF during continuous intravenous administration of CDH, and CDH did not affect the NA-induced increase in MAP. The administration of exogenous AngII (100 ng/kg) increased MAP and decreased RBF and heart rate, but a bolus injection of AngII did not decrease RBF during continuous intravenous administration of CDH. These results suggest that CDH plays a protective role against the pressor effects and the decrease in RBF induced by NA or AngII.

UNLABELLED: Nasotracheal intubation is often required during dental and maxillofacial surgery. The complications of nasotracheal intubation are well documented, but there have been few systematic attempts to find methods for their prevention. We examined intubation-related carriage of bacteria, especially methicillin-resistant Staphylococcus aureus (MRSA), into the trachea and evaluated the effects of topical nasal treatment with mupirocin on intubation-related bacterial colonization. Of 38 patients without mupirocin treatment (nontreatment group), 27 (71.1%) showed general bacterial colonization in the nasal cavities before intubation. MRSA was isolated from 13.2% of the patients in this group. However, 10 of 22 patients (45%) treated with mupirocin (treatment group) showed colonization by general bacteria, and 2 (9%) were MRSA carriers before intubation. After nasal intubation, general bacteria and MRSA were isolated from the endotracheal tube tip in 66.2% and 16.7% of these patients in the nontreatment group, respectively. In contrast, general bacteria were isolated from the endotracheal tube tip in 19.2% of these patients after oral intubation, but no MRSA was detected. However, after nasal intubation, general bacteria were isolated from the endotracheal tube tip in 3 of the patients in the treatment group (23.1%), and no MRSA was detected, whereas no bacteria were isolated from oral intubation tubes. These results indicate that bacteria were carried into the trachea at a more frequent rate by nasal intubation as compared with oral intubation, and nasal treatment with mupirocin eliminated the nasal carriage of S. aureus. Topical nasal treatment with mupirocin before nasal intubation is thus suggested to be effective for preventing carriage of bacteria into the trachea. IMPLICATIONS: We studied the carriage rate of bacteria into the trachea caused by nasal intubation. The bacterial carriage by nasal intubation was more frequent than that by oral intubation, and intranasal administration of mupirocin eliminated the carriage of S. aureus. These results indicate that topical nasal treatment with mupirocin is effective to prevent carriage of bacteria into the trachea.

IMPLICATIONS: Epirubicin, an anticancer drug, causes cardiotoxicity. We reported a case of sino-atrial block during general anesthesia in a woman with breast cancer who had received epirubicin. Anesthesiologists should be aware of the possible occurrence of sino-atrial block with epirubicin, and planting a pacemaker might be considered even in asymptomatic patients.

We report here the effects of an environmental estrogen, bisphenol A, on norepinephrine (NE) transporter function in cultured bovine adrenal medullary cells. The effects of bisphenol A were compared to those of 17beta-estradiol. Bisphenol A significantly inhibited [3H]NE uptake by the cells in a concentration-dependent manner (1-100 microM). Kinetic analysis revealed that bisphenol A, as well as 17beta-estradiol, noncompetitively inhibited [3H]NE uptake. Bisphenol A and 17beta-estradiol inhibited the specific binding of [3H]desipramine to plasma membranes isolated from bovine adrenal medulla. As shown by Scatchard analysis of [3H]desipramine binding, bisphenol A increased the dissociation constant (K(d)) and decreased the maximal binding (B(max)), indicating a mixed type of inhibition. 17beta-Estradiol increased the K(d) without altering the B(max), thereby indicating competitive inhibition. The present findings suggest that bisphenol A inhibits the function of the NE transporter by acting on a site different from that of 17beta-estradiol in the adrenal medulla and probably in the brain noradrenergic neurons.