[in Japanese]

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The level of cytokines in septic patients may be closely related to the severity of the illness. This study was performed in four patients with septic shock who received continuous infusion of methylprednisolone (MPS) for 48 hours. We observed changes in various cytokine levels and in clinical symptoms after the administration of MPS.
The initial dose of MPS of 5mg/kg was given in one bolus intravenously, followed by continuous infusion of MPS (0.65mg/kg/h) for 48 hours. Blood levels of TNFα, IL-6, and IL-8 were measured by the ELISA method. The blood level of MPS was also measured. The MPS level reached 2mcg/ml 0.5 hours after the start of MPS infusion, and remained around 2-4mcg/ml thereafter.
After administration of MPS, all cytokine levels declined sharply. Increase in P/F ratio and decrease in CRP level followed. Clinical symptoms also improved the clinical state improved in proportion to the decline in cytokine levels.
The above findings suggest that continuous infusion of MPS may be an effective therapy for hypercytokinemic patients.

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Hepatic dysfunction following cardiopulmonary bypass (CPB) is a common phenomenon that may increase mortality. Hepatic dysfunction may be a consequence of inadequate liver perfusion during CPB. We monitored hepatic venous oxyhemoglobin saturation (ShVO₂) during CPB continuously in 8 patients. The mean value of ShVO₂was 63.0±9.4 % before CPB. ShVO₂ increased with cooling and remained until rewarming was completed. ShVO₂ started to decline following rewarming and decreased to 36.6±16.6 % when CPB was completed. ShVO₂ was 63.0±11.3%, equal to the initial value, one hour after CPB. Our findings indicate that temperature change during the rewarming period is an important factor affecting the balance of hepatic oxygen supply and demand during CPB.

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Vecuronium, a nondepolarizing neuromuscular blocker, is thought to have minimal adverse cardiovascular effects, but it has been reported to produce bradycardia, sinus arrest and hypotension in some patients. We experienced severe hypotension when vecuronium was administered to a patient with marked autonomic nervous system dysfunction due to severe tetanus in the phase of sympathetic overactivity. An 81-year-old woman had been admitted to our ICU with a diagnosis of tetanus, and she fell into the sympathetic overactivity syndrome 10 days after admission. When vecuronium 12mg was administered to facilitate mechanical ventilation, her blood pressure fell to 50/30mmHg from baseline 160/64mmHg. When pancuronium 8mg was administrated after hemodynamics became stable, blood pressure rose to 166/79mmHg from baseline 132/59mmHg. This indicates that vecuronium has adverse cardiovascular effects, especially for patients with autonomic nervous dysfunction.

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A case of periodic repetition of coronary spasm was observed after injection of bupivacaine into the thoracic epidural space. A 72-year-old man underwent upper lobectomy of the left lung for the treatment of lung cancer. He showed no symptoms suggesting ischemic heart disease before the operation. After the operation, 4ml of 0.25%bupivacaine was injected into the thoracic epidural space. From 20 until 180 minutes after the injection, coronary spasm occurred 12 times. No hyperventilation, alkalosis, hypoxia, or abnormal electrolytes were observed during this 160-minute period. The first coronary spasm almost coincided with the time epidural bupivacaine was expected to begin showing its effect, suggesting that injection of bupivacaine into the thoracic epidural space induced coronary spasm in the present case.

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A 56-year-old man with renal cell carcinoma extending into the right atrium underwent radical nephrectomy with tumor thrombus extraction. Cardiopulmonary bypass was performed without cardiac arrest. After cardiopulmonary bypass was discontinued, intractable bleeding from the resected surface resulted in circulatory collapse. A roller pump for hemodialysis was utilized to infuse blood rapidly. It is important to monitor the pressure within the infusion line in order to prevent iatrogenic vascular injuries after pressurized infusion. Further study will be necessary to minimize the risk of tumor cell recirculation during intraoperative salvaged autologous transfusion.

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