Faculty Profiles - BABA Hiroshsi

A case of profound bradycardia and cardiac arrest during left upper lobectomy and lymph node dissection Reviewed

Tomohiro Yamamoto, Takayuki Honma, Miho Ikoma, Hiroshi Baba, Tatsuro Kohno

Japanese Journal of Anesthesiology 59 ( 12 ) 1483 - 1486 2010.12

Language：Japanese Publishing type：Research paper (scientific journal)

We present a case of profound bradycardia and cardiac arrest in a 61-year-old man, which occurred during left upper lobectomy and lymph node dissection for the ligamentum arteriosum. General anesthesia was maintained by propofol TIVA combined with epidural anesthesia. During the electrocautery dissection of the lymph node of the ligamentum arteriosum the patient became extremely bradycardic for 10 min. Subsequent traction with forceps further aggravated the bradycardia leading to cardiac arrest. In order to continue the procedure, we initiated epicardial pacing and switched to isoflurane anesthesia. Given the close proximity of the lymph node of the ligamentum arteriosum to the thoracic cardiac branch of the vagus nerve and the cardiac plexus, we believe that the observed bradycardia and cardiac arrest are likely attributable to vasovagal stimulation.

[Anesthetic management of Menkes disease infant with difficult vascular access]. Reviewed

Takayuki Yoshida, Kenta Furutani, Takeshi Hashimoto, Miki Taneoka, Toshiyuki Tobita, Hiroshi Baba

Masui. The Japanese journal of anesthesiology 59 ( 10 ) 1280 - 3 2010.10

Language：Japanese Publishing type：Research paper (scientific journal)

We report anesthetic management of a 6-month-old boy with Menkes disease who underwent three surgeries for vesicoureteral reflux, rupture of the bladder diverticulum, inguinal hernia, and gastroesophageal reflux. Menkes disease is a rare sex-linked disorder of copper absorption and metabolism. Anesthetic management of such patients is rather challenging because of high incidence of seizures, gastroesophageal reflux with the risk of aspiration, hypothermia, airway and vascular complications. In our patient general anesthesia was uneventfully maintained by sevoflurane combined with intravenous remifentanil and fentanyl. We experienced no major complications except some difficulties with intravenous and arterial cannulation. It was especially difficult to establish intravenous and invasive blood pressure lines because of tortuous blood vessels in this patient. We conclude that in patients with Menkes disease scheduled for surgery intravenous access should be established before the induction of general anesthesia. The necessity of invasive blood pressure monitoring should be also carefully considered beforehand.

血管確保に難渋したメンケス病患児の全身麻酔経験 Reviewed

吉田敬之, 古谷健太, 橋本武志, 種岡美紀, 飛田俊幸, 馬場洋

麻酔 59 ( 10 ) 1280-3 2010.10

Can intraoperative TEE correctly measure residual shunt after surgical repair of ventricular septal defects? Reviewed

Satoshi Kurokawa, Takayuki Honma, Miki Taneoka, Hidekazu Imai, Hiroshi Baba, Minoru Nomura

JOURNAL OF ANESTHESIA 24 ( 3 ) 343 - 350 2010.6

Language：English Publishing type：Research paper (scientific journal) Publisher：SPRINGER TOKYO

No groups have yet succeeded in identifying the need for re-repair of residual shunt after surgical repair of ventricular septal defect (VSD) based on quantitative evaluation of the ratio of the pulmonary blood flow to the systemic blood flow (Qp/Qs) by transesophageal echocardiography (TEE). Hence, we studied the accuracy of Qp/Qs as estimated by intraoperative TEE.
Twenty-six patients undergoing VSD closure were studied. After separation from the cardiopulmonary bypass, the presence and severity of residual leakage was evaluated by color Doppler image, and the Qp/Qs (TEE-derived Qp/Qs) was calculated by measuring the vessel diameter and the velocity-time integral of the flow profiles in the main pulmonary artery and left ventricular outflow tract. Transthoracic echocardiography (TTE) was performed at pre-discharge and at 6-12 months after the correction to confirm the presence and severity of residual leakage.
TEE detected only minor leakage, with no indication for re-repair, in 8 of the 26 patients. Nevertheless, TEE-derived Qp/Qs varied from 0.57 to 2.07 and were incorrect in 17 patients (65.4%). This meant that when TEE-derived Qp/Qs was outside the acceptable range, the patient was judged not to be in need of re-repair. TTE at pre-discharge confirmed trivial leakage in 3 patients in whom TEE had also identified similar leakages. These leakages were not observed at the follow-up TTE.
TEE-derived Qp/Qs lacks the accuracy required to play a crucial role in quantitatively measuring the severity of residual shunt, while two-dimensional TEE can reliably detect residual leakage after VSD closure and lead to optimal judgment on the need for re-repair.

File： Kurokawa(JA, 2010).pdf

DOI： 10.1007/s00540-010-0896-3

A case of central cord syndrome following thyroidectomy Reviewed

Tatsunori Watanabe, Daisuke Takizawa, Tsuyoshi Sato, Hisashi Masaki, Michiya Ohkuro, Toshiyuki Tobita, Hiroshi Baba

JOURNAL OF CLINICAL ANESTHESIA 22 ( 4 ) 307 - 309 2010.6

Xenon inhibits excitatory but not inhibitory transmission in rat spinal cord dorsal horn neurons Reviewed

Stefan K. Georgiev, Hidemasa Furue, Hiroshi Baba, Tatsuro Kohno

MOLECULAR PAIN 6 25 2010.5

Language：English Publishing type：Research paper (scientific journal) Publisher：BIOMED CENTRAL LTD

Background: The molecular targets for the promising gaseous anaesthetic xenon are still under investigation. Most studies identify N-methyl-D-aspartate (NMDA) receptors as the primary molecular target for xenon, but the role of alpha-amino-3-hydroxy-5-methyl-4-isoxazole-4-propionic acid (AMPA) receptors is less clear. In this study we evaluated the effect of xenon on excitatory and inhibitory synaptic transmission in the superficial dorsal horn of the spinal cord using in vitro patch-clamp recordings from rat spinal cord slices. We further evaluated the effects of xenon on innocuous and noxious stimuli using in vivo patch-clamp method.
Results: In vitro, xenon decreased the amplitude and area under the curve of currents induced by exogenous NMDA and AMPA and inhibited dorsal root stimulation-evoked excitatory postsynaptic currents. Xenon decreased the amplitude, but not the frequency, of miniature excitatory postsynaptic currents. There was no discernible effect on miniature or evoked inhibitory postsynaptic currents or on the current induced by inhibitory neurotransmitters. In vivo, xenon inhibited responses to tactile and painful stimuli even in the presence of NMDA receptor antagonist.
Conclusions: Xenon inhibits glutamatergic excitatory transmission in the superficial dorsal horn via a postsynaptic mechanism. There is no substantial effect on inhibitory synaptic transmission at the concentration we used. The blunting of excitation in the dorsal horn lamina II neurons could underlie the analgesic effect of xenon.

File： Georgiev(Mol Pain,2010).pdf

DOI： 10.1186/1744-8069-6-25

Epidural anesthesia with noninvasive positive pressure ventilation in a patient with compromised respiratory function Reviewed

Hiroyuki Honda, Takayuki Honma, Hiroshi Baba

Japanese Journal of Anesthesiology 59 ( 4 ) 467 - 469 2010.4

Language：Japanese Publishing type：Research paper (scientific journal)

We report successful epidural anesthetic management in a patient with severely impaired respiratory function. A 47-year-old woman (39 kg, 158 cm) was scheduled for right thoracoplasty. She had undergone fenestration surgery for empyema three months previously and required supplemental oxygen. Her vital capacity was 700 ml and forced expiratory volume in one second was 650 ml, indicating a severe restrictive pulmonary disorder. Hence, in order to avoid general anesthesia with tracheal intubation, we opted for epidural anesthesia. An epidural catheter was inserted in the T6-7 interspace and a bolus of 4.5 ml each of 1% mepivacaine and 1% ropivacaine was injected through the epidural catheter after a test dose. Ten minutes after the injection, the patient complained of difficulty in breathing and her oxygen saturation fell from 96% to 93%. We applied noninvasive positive pressure ventilation (NPPV) via a nasal mask to the patient, with the ventilator set at spontaneous/timed mode with inspiratory/expiratory positive airway pressure of 14/5 cmH2O. With this therapy, the patient's respiratory symptoms subsided rapidly and we could maintain adequate oxygenation and ventilation throughout the operation. We believe that epidural anesthesia with NPPV is a useful option for patients with compromised respiratory function.

胸部硬膜外麻酔に非侵襲的陽圧換気を併用した低肺機能患者の麻酔管理

本田博之, 本間隆幸, 馬場洋

麻酔 59 ( 4 ) 467 - 469 2010.4

Language：Japanese Publisher：克誠堂出版(株)

47歳女。7年前両側特発性乳び胸と診断された。次第に呼吸状態悪化のため、7ヶ月前胸管結紮術を施行し、術後肺炎のため約1ヵ月人工呼吸管理を要した。3ヵ月前に難治性の膿胸に対し右胸腔開窓術を施行し、夜間の非侵襲的陽圧換気(NPPV)および労作時酸素吸入を要する状態となったが、膿胸は改善し右胸郭形成術を予定した。Hugh-Jones分類IV度で、胸部X線で左側に若干の胸水貯留と下肺野浸潤影を認めた。著しい肺機能低下のため胸部硬膜外麻酔とし、硬膜外カテーテルよりメピバカインとロピバカインの等量混合液を投与した。SpO2低下のため鼻マスクによるNPPV導入し呼吸困難は消失した。局所麻酔薬投与から15分後にT1-12の冷覚消失を確認して手術を開始した。鎮静にプロポフォールを投与し、血圧低下は輸液負荷とエフェドリン投与で対処した。手術は肋骨部分切除、肋間筋を含む周囲軟部組織の胸腔内充填を行った。閉胸時に軽度の疼痛を訴え、同じ局所麻酔薬混合液を追加投与し自発呼吸を維持して手術を遂行した。NPPV中止で酸素飽和度低下もなく、術後鎮痛にロピバカインを3日間持続硬膜外投与した。呼吸状態も良好に経過して退院した。

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Genetic reduction of GABA(A) receptor gamma 2 subunit expression potentiates the immobilizing action of isoflurane Reviewed

Kenji Seo, Hiroyuki Seino, Hiroyuki Yoshikawa, Andrey B. Petrenko, Hiroshi Baba, Naoshi Fujiwara, Genji Someya, Yoshiro Kawano, Takeyasu Maeda, Masato Matsuda, Takashi Kanematsu, Masato Hirata

NEUROSCIENCE LETTERS 472 ( 1 ) 1 - 4 2010.3

Language：English Publishing type：Research paper (scientific journal) Publisher：ELSEVIER IRELAND LTD

Potentiation of inhibitory gamma-aminobutyric acid subtype A (GABA(A)) receptor function is involved in the mechanisms of anesthetic action. The present study examined the immobilizing action of the volatile anesthetic isoflurane in mice with double knockout (DKO) of phospholipase C-related inactive protein (PRIP)-1 and -2. Both of these proteins play important roles in the expression of GABA(A) receptors containing the gamma 2 subunit on the neuronal cell surface. Immunohistochemistry for GABA(A) receptor subunits demonstrated reduced expression of gamma 2 subunits in the spinal cord of the DKO mice. Immunohistochemistry also revealed up-regulation of the alpha 1 and beta 3 subunits even though there were no apparent differences in the immunoreactivities for the beta 2 subunits between wild-type and DKO mice. The tail-clamp method was used to evaluate the anesthetic/immobilizing effect of isoflurane and the minimum alveolar concentration (MAC) was significantly lower in DKO mice compared with wild-type controls (1.07 +/- 0.01% versus 1.36 +/- 0.04% atm), indicating an increased sensitivity to isoflurane in DKO mice. These immunohistochemical and pharmacological findings suggest that reduced expression of the GABA(A) receptor gamma 2 subunit affects the composition and function of spinal GABA(A) receptors and potentiates the immobilizing action of isoflurane. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

File： Seo(Neuroscience Letters, 2010).pdf

DOI： 10.1016/j.neulet.2010.01.031

Reduced Immobilizing Properties of Isoflurane and Nitrous Oxide in Mutant Mice Lacking the N-Methyl-D-Aspartate Receptor GluR epsilon 1 Subunit Are Caused by the Secondary Effects of Gene Knockout Reviewed

Andrey B. Petrenko, Tomohiro Yamakura, Tatsuro Kohno, Kenji Sakimura, Hiroshi Baba

ANESTHESIA AND ANALGESIA 110 ( 2 ) 461 - 465 2010.2

Language：English Publishing type：Research paper (scientific journal) Publisher：LIPPINCOTT WILLIAMS & WILKINS

BACKGROUND: Until recently, the N-methyl-D-aspartate (NMDA) receptor was considered to possibly mediate the immobility produced by inhaled anesthetics such as isoflurane and nitrous oxide. However, new evidence suggests that the role of this receptor in abolition of the movement response may be less important than previously thought. To provide further evidence supporting or challenging this view, we examined the anesthetic potencies of isoflurane and nitrous oxide in genetically modified animals with established NMDA receptor dysfunction caused by GluR epsilon 1 subunit knockout.
METHODS: The immobilizing properties of inhaled anesthetics in mice quantitated by the minimum alveolar anesthetic concentration (MAC) were evaluated using the classic tail clamp method.
RESULTS: Compared with wild-type controls, NMDA receptor GluR epsilon 1 subunit knockout mice displayed larger isoflurane MAC values indicating a resistance to the immobilizing action of isoflurane. Knockout mice were previously shown to have enhanced monoaminergic tone as a result of genetic manipulation, and this increase in MAC could be abolished in our experiments by pretreatment with the serotonin 5-hydroxytryptamine type 2A receptor antagonist ketanserin or with the dopamine D2 receptor antagonist droperidol at doses that did not. affect MAC values in wild-type animals. Mutant mice also displayed resistance to the isoflurane MAC-sparing effect of nitrous oxide, but this resistance was similarly abolished by ketanserin and droperidol. Thus, resistance to the immobilizing action of inhaled anesthetics in knockout mice seems to be secondary to increased monoaminergic activation after knockout rather than a direct result of impaired NMDA receptor function.
CONCLUSIONS: Our results confirm recent findings indicating no critical contribution of NMDA receptors to the immobility induced by isoflurane and nitrous oxide. In addition, they demonstrate the ability of changes secondary to genetic manipulation to affect the results obtained in global knockout studies. (Anesth Analg 2010;110:461-5)

File： Petrenko(A&A,2010).pdf

DOI： 10.1213/ANE.0b013e3181c76e73

Major factors of homologous blood transfusion in valvular heart operation with intraoperative autologous blood predonation in cases with difficulty in preoperative predonation Reviewed

Koichi Sato, Osamu Namura, Kazuhiko Hanzawa, Chizuo Kikuchi, Masaru Takekubo, Fuyuki Asami, Takashi Wakabayashi, Takeshi Saito, Takayuki Homma, Hiroshi Baba, Jun-Ichi Hayashi

International Journal of Artificial Organs 33 ( 2 ) 72 - 75 2010.2

Language：English Publishing type：Research paper (scientific journal)

Intraoperative autologous blood predonation is reported to be useful for the prevention of homologous blood transfusion in cardiac operations, especially in on-pump coronary artery bypass grafting (CABG). However, CABG is now performed more often off-pump than on-pump. We analyzed the major factors of homologous blood transfusion in 25 consecutive cases of valvular heart operation with intraoperative autologous blood predonation except those with preoperative autologous blood donation. Homologous blood was not transfused in 18 cases, but was in 7 cases only after cardiopulmonary bypass (CPB). The homologous transfusion was not correlated with body weight, CPB dilution or duration, or preoperative hematocrit level, but was found to correlate with age (R 2=0.289, p=0.0413), bleeding output (R2=0.197, p=0.0485), and predonation blood volume (R2=0.436, p=0.0152). In conclusion, suitable intraoperative predonation may reduce the necessity for homologous blood transfusion in valvular heart operations. © 2010 Wichtig Editore.

DOI： 10.1177/039139881003300202

Bupivacaine Inhibits Glutamatergic Transmission in Spinal Dorsal Horn Neurons Reviewed

Kenta Furutani, Miho Koma, Hideaki Ishii, Hiroshi Baba, Tatsuro Kohno

ANESTHESIOLOGY 112 ( 1 ) 138 - 143 2010.1

Language：English Publishing type：Research paper (scientific journal) Publisher：LIPPINCOTT WILLIAMS & WILKINS

Background: The local anesthetic bupivacaine is thought not only to block sodium channels but also to interact with various receptors. Here, the authors focus on excitatory glutamatergic transmission in the superficial dorsal horn of the spinal cord with respect to its importance for nociceptive processing.
Methods: The effects of bupivacaine on the response to exogenous administration of N-methyl-D-aspartate (NMDA) receptor agonists were examined in lamina II neurons of adult rat spinal cord slices using the whole-cell patch-clamp technique.
Results: Bupivacaine (0.5, 2 mM) dose-dependently reduced the peak amplitudes of exogenous NMDA-induced currents. However, this inhibitory effect of bupivacaine (2 mM) was not blocked by the presence of tetrodotoxin, a sodium channel blocker, or La(3+) , a voltage-gated Ca(2+) channel blocker, and was unaffected by changes in pH conditions. Moreover. intrapipette guanosine-5'-O-(2-thiodiphosphate) (1 mM), a G-protein inhibitor, did not block the reduction of NMIDA current amplitudes by bupivacaine. Similarly, lidocaine, ropivacaine, and mepivacaine also reduced the amplitudes of NMDA-induced currents.
Conclusions: These findings raise the possibility that the antinociceptive effect of bupivacaine may be due to direct modulation of NMDA receptors in the Superficial dorsal horn. In addition to voltage-gated sodium channels, glutamate NMDA receptors are also important for analgesia induced by local anesthetics.

File： Furutani(Anesthesiology,2010).pdf

DOI： 10.1097/01.anes.0000365964.97138.9a

Nitrous oxide and the inhibitory synaptic transmission in rat dorsal horn neurons Reviewed

Stefan K. Georgiev, Hiroshi Baba, Tatsuro Kohno

EUROPEAN JOURNAL OF PAIN 14 ( 1 ) 17 - 22 2010.1

Language：English Publishing type：Research paper (scientific journal) Publisher：ELSEVIER SCI LTD

The analgesic effect of nitrous oxide (N(2)O) is thought to depend on noradrenaline release in the spinal cord following activation of descending inhibitory neurons. In addition to this indirect facilitation of inhibition in the spinal cord, we previously showed direct inhibition of glutamate receptors in dorsal horn neurons by N(2)O. Since general anesthetics could possibly affect excitatory and/or inhibitory components of synaptic transmission, we sought to evaluate the direct effect of N(2)O on inhibitory transmission in spinal cord neurons.
Using whole-cell patch-clamp recording from rat transversal spinal cord slices, we investigated the actions of 50% N(2)O and 0.5% isoflurane (both 0.3 rat MAC: minimum alveolar concentration) on exogenously applied gamma-aminobutyric acid (GABA)- and glycine-induced currents in rat dorsal horn lamina II neurons. The amplitudes and integrated areas of GABA- and glycine-induced currents were not significantly affected by N(2)O, but were increased in the presence of isoflurane. N(2)O did not affect the amplitude, frequency or decay time probability distribution of either GABA or glycine receptor-media red miniature postsynaptic currents. We further sought to determine the effect of N(2)O On focal stimulation-evoked synaptic Currents mediated by GABA and glycine receptors, and found no effect in the majority of neurons.
These and other findings suggest that N(2)O has a discrete action in the spinal cord, distinct from the effects of the volatile anesthetics, consisting of inhibition of excitation in SG neurons through an action on ionotropic glutamatergic receptors and potentiation of inhibition through the descending noradrenergic system. (C) 2009 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.

File： Georgiev(Eur J Pain,2010).pdf

DOI： 10.1016/j.ejpain.2009.01.008

[Anesthetic management of a child with congenital myotonic dystrophy and perioperative hypoxia]. Reviewed

Kenta Furutani, Michiya Ohkuro, Reiko Komura, Takayuki Honma, Naoki Saito, Hiroshi Baba

Masui. The Japanese journal of anesthesiology 58 ( 2 ) 183 - 6 2009.2

Language：Japanese Publishing type：Research paper (scientific journal)

A 7-year-old boy with congenital myotonic dystrophy (MD) and developmental retardation underwent an emergency surgery for strangulation ileus. General anesthesia was maintained using sevoflurane and fentanyl. While intraoperative arterial blood pressure, pulse and rectal temperature remained stable, the arterial blood oxygenation gradually deteriorated during the procedure. We suspected the existence of atelectasis or some other obstructive lung lesion to be the underlying cause, and performed bronchoscopic examination which revealed a collapse of the left main bronchus. Therefore, postoperative mechanical ventilation was continued for several hours in the ICU. According to the postoperative computed tomography, the left main bronchus was sandwiched between the aortic arch and thoracic vertebra. It has been reported that MD patients have a risk of perioperative pulmonary complications, particularly in those who have severe muscular disability undergoing upper abdominal surgery. These risk factors combined with bronchial stenosis could have caused intraoperative hypoxia in our patient. We conclude that when a severe MD patient is scheduled for an upper abdominal surgery, mechanical ventilation should be considered until spontaneous recovery from muscle relaxants occurs. Also, since MD has been related to malignant hyperthermia, total intravenous anesthesia, possibly combined with regional blockade, is a preferable method of anesthesia for such patients.

Massive hemorrhage during cesarean section for placenta accreta Reviewed

Reiko Komura, Takashi Mochida, Hidekazu Imai, Chieko Shibue, Toshiyuki Tobita, Hiroshi Baba

Japanese Journal of Anesthesiology 58 ( 2 ) 215 - 218 2009.2

Language：Japanese Publishing type：Research paper (scientific journal)

A 37-year-old multigravida presented at 37 weeks of gestation with low-lying placenta and highly suspected placenta accreta. The placenta adhered widely to the anterior wall of the uterus. Therefore, a longitudinal incision of the uterine corpus at the thinnest part of the placenta was made during surgery. Concurrent with the incision, rapid and massive hemorrhage occurred. After the delivery of the baby and confirmation of the placental adhesion, the hysterectomy was started promptly. The bladder adhered strongly to the uterus, and was injured during the dissection. The total volume of hemorrhage was estimated to be 24,480 ml (including amniotic fluid and urine). No arterial clamp for hemostasis was used during the procedure. The patient was discharged on the 12th postoperative day with no sequela. The pathological diagnosis was placenta percreta. Placenta accreta is a rare disease with a high mortality rate. The hemorrhage becomes difficult to control in case of injury of placenta accreta. The hysterectomy following cesarean section also becomes complicated. Bladder injury is one of the complications of the cesarean hysterectomy which makes the hemorrhage greader. In conclusion, when placenta accreta is suspected a strategy to minimize blood loss during surgery should be discussed by a multidisciplinary team.