bluuebunny/crossref_metadata_2025 huggingface dataset:
Keeping the spirit high: why trauma team training is (sometimes) implemented
Authors: WISBORG T. , BRATTEBØ G.
Published: August 2010

Background: Systematic and multiprofessional trauma team training using simulation was introduced in Norway in 1997. The concept was developed out of necessity in two district general hospitals and one university hospital but gradually spread to 45 of Norway's 50 acute‐care hospitals over the next decade. Implementation in the hospitals has varied from being a single training experience to becoming a regular training and part of quality improvement. The aim of this study was to better understand why only some hospitals achieved implementation of regular trauma team training, despite the intentions of all hospitals to do so.

Methods: Focus group interviews were conducted with multiprofessional respondents in seven hospitals, including small and large hospitals and hospitals with and without regular team training. Interviews were transcribed and analyzed using a Grounded Theory approach.

Results: ‘Keeping the spirit high’ appeared to be the way to achieve implementation. This was achieved through ‘enthusiasm,’‘strategies and alliances,’ and ‘using spin‐offs.’ It seems that the combination of enthusiasts, managerial support, and strategic planning are key factors for professionals trying to implement new activities.

Conclusions: Committed health professionals planning to implement new methods for training and preparedness in hospitals should have one or more enthusiasts, secure support at the administrative level, and plan the implementation taking all stakeholders into consideration.
Pain and disability 1 year after knee arthroscopic procedures
Authors: ROSSELAND L. A. , SOLHEIM N. , STUBHAUG A.
Published: August 2010

Background: Persistent chronic pain after surgery is a major health care problem. Its prevalence after knee arthroscopy is unknown. We conducted a follow‐up of knee arthroscopy patients. The aims were to estimate the prevalence of pain at rest and during activity 1 year after knee arthroscopy.

Methods: One hundred patients with moderate or severe acute pain after knee arthroscopy were included in one of two randomized‐controlled pain trials. A questionnaire was mailed to all the patients 1 year after inclusion.

Results: The prevalence of pain at rest 1 year after surgery [numeric rating scale (NRS) 0–10 grade ≥1] was 30% (95% CI 17–47) in women and 29% (95% CI 17–46) in men. Four of 33 female (10%) and three of 34 male patients (9%) experienced pain intensities at rest of NRS>4, and the number of patients who had experienced NRS>4 during activities were 7 (21%) and 4 (11%), respectively. Age above 50 years was positively correlated to persistent pain. The number of patients who reported a reduced activity of daily living (ADL) due to pain (NRS>4) was 14 of 33 (42%, 95% CI 28–56%) in female and five of 34 (15%, 95% CI 5–25%) in male patients (P=0.03). Age above 50 years was positively correlated to impaired ADL function due to knee pain.

Conclusions: Persistent pain after knee arthroscopy may be a significant health care problem. Age and female gender are independent risk factors for pain and disability 1 year after surgery.
Propofol reduces nitric oxide‐induced apoptosis in testicular ischemia–reperfusion injury by downregulating the expression of inducible nitric oxide synthase
Authors: YAGMURDUR H. , AYYILDIZ A. , KARAGUZEL E. , AKGUL T. , USTUN H. , GERMIYANOGLU C.
Published: August 2010

Background: The aim of the present study was to investigate the underlying mechanisms in the preventive effects of intravenous anesthetics on testicular ischemia–reperfusion injury.

Methods: Forty male Wistar Albino rats were randomly assigned to four groups of 10 rats each. Anesthesia was induced and maintained with thiopental in groups 1 and 2 and with propofol in groups 3 and 4. Groups 2 and 4 received left testicular ischemia (torsion) for 1 h and reperfusion (detorsion) for 24 h. Groups 1 and 3 (control groups) had no testicular torsion and detorsion. At 24 h of reperfusion, animals were killed and ipsilateral testes were removed for determination of tissue nitric oxide (NO) levels and immunohistochemical evaluation of endothelial nitric oxide synthase (eNOS), inducible NOS (iNOS), and apoptosis protease‐activating factor 1 (APAF‐1).

Results: Between groups 1 and 3, there were no differences in tissue NO levels and eNOS, iNOS, and APAF‐1 expressions. iNOS and APAF‐1 expressions were markedly increased in group 2, but these parameters were at the mild to moderate level in group 4 at 24 h of reperfusion. Also, elevated expression of iNOS was accompanied by a high NO production in group 2 compared with group 4. Although eNOS expressions were increased in both the groups (groups 2 and 4), there were no significant differences between these groups.

Conclusions: Propofol as an anesthetic agent may attenuate germ cell‐specific apoptosis and decrease NO biosynthases through downregulation of iNOS expression in an animal model of testicular torsion and detorsion.
Effect of propofol on pathologic time‐course and apoptosis after cerebral ischemia–reperfusion injury
Authors: CHEN L. , XUE Z. , JIANG HAO
Published: August 2010

Background: Propofol has been demonstrated to ameliorate cerebral ischemic injury and attenuate changes in multiple links of molecular reaction included in the paths to apoptosis. The experiment was aimed to evaluate whether propofol neuroprotection was mediated through the ability to regulate pathologic time‐course of apoptosis.

Methods: The effect of propofol given at a series of time points during ischemia–reperfusion period was determined using an intraluminal middle cerebral artery occlusion model in rats. The morphological changes of apoptosis under different duration of ischemia were detected by terminal deoxynucleotidyl transferase (TdT)‐mediated dUTP‐biotin in situ nick labeling staining, and the effect of propofol on apoptosis was observed. The expression of anti‐apoptotic protein bcl‐2 in post‐ischemia neurons and the influence of propofol was analyzed by immunochemistry staining.

Results: Propofol attenuated neurological deficit, reduced infarct volumes, when given prior the onset of ischemia, during ischemia or 3 h after reperfusion. Apoptosis obviously appeared at 6 h post‐reperfusion preceded by 90 min ischemia, rose to the maximum value at 24 h post‐reperfusion and gradually diminished after 3 days reperfusion. Propofol inhibited apoptotic morphological changes between 6 h and 3 days post‐reperfusion. Propofol enhanced the expression of anti‐apoptotic protein bcl‐2 in post‐reperfusion neurons.

Conclusions: The pathologic outcome of focal cerebral ischemia–reperfusion injury was displayed by co‐existence of apoptosis and necrosis. A short duration of ischemia induced apoptosis. The therapeutic window for propofol initiated before the onset of ischemia and lasted until early stage of reperfusion. The neuroprotection of propofol might be attributed to the inhibition of apoptosis.
Thoracic epidural catheterization leading to delayed transient neurological symptoms with normal imaging findings
Authors: MATHUR S. K. , CHAKRABORTY A. , JAIN S. , JAIN A.
Published: August 2010

Paraparesis after epidural catheterization is rare but may be multifactorial. We report a case of temporary paraparesis in a 32‐year‐old female patient after thoracic epidural catheterization performed analgesia. A 16 G epidural needle was introduced at the T7–T8 interspace but as frank blood came through, it was withdrawn and was reinserted at the T8–T9 interspace. An 18 G epidural catheter was introduced and 10 ml of 0.125% bupivacaine with buprenorphine 150 mcg was given. Further top‐ups were given for 48 h on complain of pain. There was an episode of hypotension after giving the epidural drug but later on the patient remained haemodynamically stable. On the fourth post‐operative day, the patient reported paraparesis with heaviness and tingling sensation in both lower extremities. MRI was normal with no evidence of spinal cord compression, oedema, haematoma or abscess. The patient improved gradually within a period of 3 days. The possible causes of delayed onset of neurological symptoms are discussed.
Ropivacaine and levobupivacaine for bilateral selective ankle block in patients undergoing hallux valgus repair
Authors: PALMISANI S. , ARCIONI R. , DI BENEDETTO P. , DE BLASI R. A. , MERCIERI M. , RONCONI P.
Published: August 2010

Background: A selective ankle block, blocking the tibial, deep and superficial peroneal nerves, can be used successfully for great toe surgery. No comparative information is available on selective ankle block using ropivacaine and levobupivacaine.

Methods: We compared the onset time and success rate of a selective ankle block using low volumes (12 ml) of ropivacaine 10 mg/ml and levobupivacaine 7.5 mg/ml in 40 patients undergoing elective repair of bilateral hallux valgus. Each patient received an ankle block induced in one foot with ropivacaine and in the contralateral foot with levobupivacaine.

Results: The success rate was higher [90% vs. 75%, hazard ratio (95% CI) 0.39 (0.23–0.64)] and anesthesia onset time was shorter (median, 10 vs. 20 min) after ropivacaine than after levobupivacaine. In successful ankle blocks, post‐operative pain was similar in the two groups.

Conclusion: In this study, ropivacaine 10 mg/ml had a shorter anesthesia onset time and a higher success rate than levobupivacaine 7.5 mg/ml for selective ankle block.
Effects of halothane, isoflurane, and sevoflurane on lipid peroxidation following experimental closed head trauma in rats
Authors: YURDAKOC A. , GUNDAY I. , MEMIŞ D.
Published: August 2010

Background: In a rat closed head trauma model we examined both the time course of lipid peroxidation and the effects of halothane, isoflurane, and sevoflurane on it by analysis of malondialdehyde (MDA) formation.

Methods: Animals were divided randomly into five groups: sham‐operated (SO), n=18; control‐closed head trauma to left frontal pole, n=18; closed head trauma model+halothane, n=18; closed head trauma model+isoflurane, n=18; and closed head trauma model+sevoflurane, n=18. Halothane, isoflurane, or sevoflurane were applied 15 min after trauma for 30 min. Rats were euthanized 1,3, and 5 h after the inhalation agents. Brain tissue samples were taken 5 mm from the left and right frontal poles. MDA was considered to reflect the degree of lipid peroxidation.

Results: MDA concentrations were greater in the control, halothane, sevoflurane, and isoflurane groups than in SO animals (P<0.001). No statistical difference between the hemispheres was found between the halothane, isoflurane, or sevoflurane groups, but MDA levels were lower with isoflurane than in the halothane, sevoflurane, and control groups at 1, 3, and 5 h (P<0.001). MDA levels were higher as compared with the halothane and sevoflurane groups at 1 h but not at 3 or 5 h (P<0.001).

Conclusion: MDA levels with the isoflurane group were lower than in the other trauma groups, which suggest that isoflurane, given after closed head trauma, might be protective against lipid peroxidation of cerebral injury.
Oxycodone vs. fentanyl in the treatment of early post‐operative pain after laparoscopic cholecystectomy: a randomised double‐blind study
Authors: KOCH S. , AHLBURG P. , SPANGSBERG N. , BROCK B. , TØNNESEN E. , NIKOLAJSEN L.
Published: August 2010

Background:It has been suggested that oxycodone is superior to other opioids in the treatment of visceral pain. We therefore compared the effect of intravenous (i.v.) oxycodone and i.v. fentanyl on post‐operative abdominal (visceral) pain after outpatient laparoscopic cholecystectomy.

Methods:Seventy‐eight patients were randomised to intra‐ and post‐operative pain treatment with either oxycodone (n=39) or fentanyl (n=39). The patients received 10 mg oxycodone/100 μg fentanyl at the end of anaesthesia. In the post‐anaesthetic care unit (PACU), 5 mg oxycodone/50 μg fentanyl was administered to patients with moderate pain [3–5 on a numeric rating scale (NRS)], and 10 mg oxycodone/100 μg fentanyl was administered to patients with severe pain (>5 on an NRS). The following measures were recorded: intensity of pain at arrival, after 30, 60 and 90 min and at discharge from the PACU; total consumption of oxycodone/fentanyl; nausea; vomiting; sedation and pressure tolerance thresholds.

Results:The median intra‐ and post‐operative consumption of oxycodone was 15 mg (range: 10–40 mg) and the consumption of fentanyl was 200 μg (range: 100–500 μg). The intensity of abdominal pain was significantly lower in the oxycodone group at arrival (P<0.05), after 30, 60 and 90 min, and at discharge from the PACU (P<0.01). There was a strong tendency towards more side effects with oxycodone.

Conclusions:Oxycodone provided better analgesia but also more side effects, suggesting that the doses used in the present study may not be equipotent.
Acute hypomagnesaemia causing intra‐operative lower limb movements in a paraplegic patient, despite full neuromuscular blockade
Authors: OZARD J. , MOSSDORF P. , DOJA A. , WRITER H. , DOHERTY D. R.
Published: August 2010

Alterations in electrolyte homeostasis associated with major surgery, intravenous fluid therapy, malnutrition, and critical illness are common but usually non‐specific. This case report describes the sudden onset of forceful rhythmic flexion movements in both lower limbs during scoliosis surgery in a 12‐year‐old paraplegic boy with spina bifida. These movements arose despite adequate depth of anaesthesia, complete neuromuscular blockade, and treatment of hypocalcaemia. They persisted post‐operatively after reversal of neuromuscular blockade and emergence from anaesthesia. Hypomagnesaemia was identified and treated post‐operatively which coincided with cessation of the movements. We deduce hypomagnesaemia to be the aetiology of this unusual clinical presentation. This report underscores the interdependency of Ca2+and Mg2+ homeostasis in excitable tissues and emphasizes that abnormalities observed in each cation should not be considered independently. In the perioperative care of spinal fusion patients, hypocalcaemia is a well‐recognised and understood complication.
Impaired erythropoiesis after haemorrhagic shock in mice is associated with erythroid progenitor apoptosis in vivo
Authors: ROBINSON Y. , MATENOV A. , TSCHÖKE S. K. , WEIMANN A. , OBERHOLZER A. , ERTEL W. , HOSTMANN A.
Published: August 2010

Objective: Multiply traumatised patients often suffer from blood loss and from subsequent therapy‐resistant anaemia, possibly mediated by apoptosis, necrosis, or humoral factors. Therefore, the underlying mechanisms were investigated in bone marrow (BM) and peripheral blood in a murine resuscitated haemorrhagic shock (HS) model.

Methods: In healthy male mice, pressure‐controlled HS was induced for 60 min. The BM was analysed for Annexin‐V, 7‐amino‐actinomycin D, apoptotic enzymes (caspases‐3/7, ‐8, and ‐9), expression of death receptors (CD120a, CD95), mitochondrial proteins (Bax, Bcl‐2, Bcl‐x), as well as erythropoietin (EPO) receptor (EPO‐R). Blood cell count, peripheral EPO, and tumour necrosis factor‐α response were additionally monitored.

Results: Twenty‐four and 72 h after HS, EPO and EPO‐R were strongly up‐regulated in peripheral blood and BM, respectively. Decreasing numbers of erythroid progenitors in BM after HS correlated with significant apoptotic changes confirmed by increased caspases‐3/7, ‐8, ‐9 activity in total BM, death receptor CD95 and CD120a expression on erythroid progenitors, and down‐regulated mitochondrial Bcl‐2 expression in total BM. Erythroid progenitors in peripheral blood were found to be increased after 72 h.

Conclusion: Despite the massive EPO response and up‐regulation of EPO‐R, BM erythroblasts (EBs) decreased. This could be due to deficient maturation of erythroid progenitors. Furthermore, the increased intrinsic and extrinsic apoptosis activation suggests programmed death of erythroid progenitors. We propose that both apoptosis and negatively regulated erythropoiesis contribute to BM dysfunction, while erythroid progenitor egress plays an additional role.
Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation
Authors: CSONTOS C. , FOLDI V. , FISCHER T. , BOGAR L.
Published: August 2010

Background: A number of target points have been used for fluid replacement in severely burned patients. The aim of our prospective randomized study was to compare the effect of two different types of fluid resuscitation regimes on the multiple organ dysfunction score (MODS) and central venous oxygen saturation (ScvO2) in the first 3 days after injury.

Methods: Twenty‐four patients admitted to the critical care unit of a university hospital with the presence of burn injury affecting more than 15% of the body surface area and in‐hospital fluid resuscitation started within 3 h after burn injury were included. Patients were randomized into two groups. Fluid resuscitation was guided by the hourly urine output (HUO Group, n=12) or by the intrathoracic blood volume index (ITBVI Group, n=12). Invasive transpulmonary hemodynamic measurements utilizing pulse contour analysis with a single dilution technique and continuous ScvO2 measurements were performed in both groups.

Results: The mean ScvO2 was significantly lower in the HUO Group than in the ITBVI Group (P=0.024) for the first 24 h. MODS was significantly higher in the HUO Group than in the ITBVI group 48 h (P=0.024) and 72 h after injury (P=0.014). The two main outcome parameters, i.e., MODS calculated at 48 and 72 h after injury and ScvO2 were negatively correlated on day 1 (r=−0.684, P=0.004, r=−0.677, P=0.003). There were no statistical differences in clinical outcome parameters.

Conclusion: Our data suggest that ITBVI may be a better target parameter than HOU in the fluid resuscitation of severely burned patients after injury.
Pre‐hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine
Authors: BERLAC P. , HYLDMO P. K. , KONGSTAD P. , KUROLA J. , NAKSTAD A. R. , SANDBERG M.
Published: August 2010

This article is intended as a generic guide to evidence‐based airway management for all categories of pre‐hospital personnel. It is based on a review of relevant literature but the majority of the studies have not been performed under realistic, pre‐hospital conditions and the recommendations are therefore based on a low level of evidence (D). The advice given depends on the qualifications of the personnel available in a given emergency medical service (EMS). Anaesthetic training and routine in anaesthesia and neuromuscular blockade is necessary for the use of most techniques in the treatment of patients with airway reflexes. For anaesthesiologists, the Task Force commissioned by the Scandinavian Society of Anaesthesia and Intensive Care Medicine recommends endotracheal intubation (ETI) following rapid sequence induction when securing the pre‐hospital airway, although repeated unsuccessful intubation attempts should be avoided independent of formal qualifications. Other physicians, as well as paramedics and other EMS personnel, are recommended the lateral trauma recovery position as a basic intervention combined with assisted mask‐ventilation in trauma patients. When performing advanced cardiopulmonary resuscitation, we recommend that non‐anaesthesiologists primarily use a supraglottic airway device. A supraglottic device such as the laryngeal tube or the intubation laryngeal mask should also be available as a backup device for anaesthesiologists in failed ETI.
Late‐onset pulmonary edema due to propofol
Authors: INAL M. T. , MEMIS D. , VATAN I. , CAKIR U. , YILDIZ B.
Published: August 2010

Pulmonary edema after the administration of propofol has rarely been reported. In this case report, we describe pulmonary edema due to the administration of propofol during a Cesarean section and while in the intensive care unit. The skin tests demonstrated strong positive weal and flare reactions to propofol. The patient was treated successfully with mechanical ventilatory support. This report emphasizes that this fatal complication may be seen with propofol and underlying mechanisms and therapeutic approach are discussed.
Effect of mivazerol, a α2‐agonist, on striatal norepinephrine concentration during transient forebrain ischemia in rats*
Authors: KIMURA T. , SATO K. , NISHIKAWA T. , TOBE Y. , MASAKI Y.
Published: August 2010

Background: We have previously reported that mivazerol, a α2‐agonist, possibly provides neuroprotection against transient forebrain ischemia in rats. This study was designed to investigate the ability of mivazerol to attenuate ischemia‐induced increase in striatal norepinephrine concentration after transient forebrain ischemia in rats.

Methods: Male Sprague–Dawley rats, anesthetized with halothane, were assigned to one of three groups (n=10 each); control (C, normal saline 1 ml/kg), mivazerol 20 μg/kg (M20), and 40 μg/kg (M40) groups. Monitored variables included temporal muscle temperature (maintained at 37.5±0.1 °C), electroencephalogram, systolic/diastolic blood pressure, heart rate, arterial blood gases, and blood glucose concentrations. Thirty minutes after subcutaneous drug administration, forebrain ischemia was induced with hemorrhagic hypotension (systolic arterial pressure: 40–50 mmHg) and bilateral carotid artery occlusion for 10 min, and then the brain was reperfused. Norepinephrine concentration in the interstitial fluids in the striatum was analyzed using in vivo microdialysis in combination with high‐performance liquid chromatography.

Results: Ischemia resulted in a prompt increase in norepinephrine concentrations in the striatum in all groups. However, there were no significant differences in norepinephrine concentrations in the striatum between the three groups at any period.

Conclusions: Our results indicate that mivazerol did not attenuate ischemia‐induced increase in striatal norepinephrine concentration. This suggests that the possible neuroprotective property of mivazerol is not related to inhibition of norepinephrine release in the brain.
Surgical stress index as a measure of nociception/antinociception balance during general anesthesia
Authors: WENNERVIRTA J. , HYNYNEN M. , KOIVUSALO A.‐M. , UUTELA K. , HUIKU M. , VAKKURI A.
Published: August 2010

Background: No validated monitoring method is available for evaluating the nociception/antinociception balance. We assessed the surgical stress index (SSI), computed from finger photoplethysmographic waveform amplitudes and pulse‐to‐pulse intervals, in patients undergoing shoulder surgery under general anesthesia (GA) and interscalene plexus block and in patients with GA only.

Methods: In this prospective, randomized study in 26 patients, increased blood pressure (BP) or heart rate, movement, and coughing were considered to be signs of intraoperative nociception and were treated with alfentanil. GA was maintained with desflurane aiming at a State Entropy level of 50. Photoplethysmographic waveforms were collected from the contra‐lateral arm to the surgery and SSI values from 0 (no surgical stress) to 100 (maximal surgical stress) were calculated off‐line.

Results: Two minutes after skin incision, SSI had not increased in the plexus group and was lower in the plexus group (38 ± 13) compared with the controls (58 ± 13, P<0.005). Among the controls, 1 min before alfentanil administration, the SSI value was higher than during periods of adequate antinociception, 59 ± 11 vs. 39 ± 12 (P<0.01). The total cumulative need for alfentanil was higher in controls (2.7 ± 1.2 mg) compared with the plexus group (1.6 ± 0.5 mg; P=0.008). Tetanic stimulation to the ulnar region of the hand increased SSI significantly only among the patients with plexus block not covering the site of the stimulation.

Conclusion: SSI values were lower in patients with plexus block covering the sites of nociceptive stimuli. In detecting nociceptive stimuli, SSI had better performance than heart rate, BP, or response entropy.
Does isoflurane enhance rhinovirus replication and virus‐induced cytokine secretion in airway epithelial cells?
Authors: Park H.‐W. , Wang J. H. , Kim J. U. , Koo S.‐W. , Kwon H. J. , Jang Y. J.
Published: August 2010

Background: There have been no previous studies regarding the effect of volatile anesthetics on human rhinovirus (RV) infection in airway epithelial cells of patients with an upper respiratory infection (URI). We have therefore evaluated in vitro the effect of isoflurane on RV infection in airway epithelial cells.

Methods: A549 cells and RV‐infected A549 cells were treated with isoflurane for 2 or 4 h. Surface expression of intercellular adhesion molecule‐1 (ICAM‐1) was assessed by flow cytometry, and effects on the secretion of interleukin (IL)‐6 and IL‐8 were measured by ELISA. The effect on RV replication in the cells was determined by viral titer.

Results: Isoflurane treatment for 2 or 4 h had no significant effect on ICAM‐1 expression and secretion of IL‐6 and IL‐8 in control cells. Isoflurane also had no significant additional effect on RV‐induced ICAM‐1 expression and secretion of IL‐6 and IL‐8. Viral titers were not significantly influenced by isoflurane.

Conclusion: Isoflurane treatment showed no additional effects with RV on ICAM‐1 expression, secretion of IL‐6 and IL‐8, and viral titer in A549 cells. These results suggest that isoflurane itself may not increase further RV infections, inflammations, and viral replication in patients with a viral URI.
Correlation between pre‐operative metabolic syndrome and persistent blood glucose elevation during cardiac surgery in non‐diabetic patients
Authors: DONATELLI F. , CAVAGNA P. , DI DEDDA G. , CATENACCI A. , DI NICOLA M. , LORINI L. , FUMAGALLI R. , CARLI F.
Published: August 2010

Background: Cardiopulmonary‐bypass (CPB) induces hyperglycemia. There is growing evidence that perioperative maintenance of blood glucose within the physiological range improves patients' outcome. Nevertheless, perioperative normoglycemia is often difficult to achieve during surgery with CPB and the response to insulin infusion is characterized by a considerable variability. The aim of this study was to determine to what extent the presence of pre‐operative metabolic syndrome (MS) influences the blood glucose and insulin response during cardiac surgery.

Methods: Forty‐five patients scheduled for elective cardiac surgery were screened for the presence of MS according to the International Diabetes Federation definition. Patients were then assigned to two groups: those with metabolic syndrome (MSP) and those without (control). During surgery, blood glucose levels were measured in all patients and hyperglycemia was treated with a standard protocol of continuous insulin infusion.

Results: The mean blood glucose levels during CPB increased only in the MSP group (P<0.001). Mean blood glucose in control patients did not increase during CPB (P=0.4). Patients with MS received 13.3±8.4 IU of insulin during CPB, while the control group did not require insulin treatment (P<0.001). Forty percent of patients in the control group and 100% of those in the MSP group developed post‐operative insulin resistance. C‐reactive protein was higher in the MSP group before, during and at 48 h after surgery.

Conclusions: The mean blood glucose levels during CPB increased only in patients with MS, while they remained unchanged in patients in the control group.
Meta‐analysis of the diagnostic accuracy of transesophageal echocardiography for assessment of atherosclerosis in the ascending aorta in patients undergoing cardiac surgery
Authors: VAN ZAANE B. , ZUITHOFF N. P. A. , REITSMA J. B. , BAX L. , NIERICH A. P. , MOONS K. G. M.
Published: August 2010

Background: Stroke after cardiac surgery may be caused by emboli emerging from an atherosclerotic ascending aorta (AA). Epiaortic ultrasound scanning (EUS), the current ‘gold’ standard for detecting AA atherosclerosis, has not gained widespread use because there is a lack of optimized ultrasound devices, it lengthens the procedure, it endangers sterility, and there is a false belief by many surgeons that palpation is as sensitive as EUS. Furthermore there is no clear evidence proving that the use of epiaortic scanning changes outcome in cardiac surgery. Various researchers investigated the ability of transesophageal echocardiography (TEE) to discriminate between the presence and absence of AA atherosclerosis. It is acknowledged that TEE has limited value in this, but it has never been supported by a meta‐analysis estimating the true diagnostic accuracy of TEE based on all quantitative evidence. We aimed to do this using state‐of‐the‐art methodology of diagnostic meta‐analyses.

Methods: We searched multiple databases for studies comparing TEE vs. EUS for detection of atherosclerosis. A random‐effects bivariate meta‐regression model was used to obtain summary estimates of sensitivity and specificity, incorporating the correlation between sensitivity and specificity as well as covariates to explore heterogeneity across studies.

Results: We extracted six studies with a total of 346 patients, of whom 419 aortic segments were analyzed, including 100 segments with atherosclerosis [median prevalence 25% (range 17–62%)]. Summary estimates of sensitivity and specificity were 21% (95% CI 13–32%) and 99% (96–99%), respectively.

Conclusions: Because of the low sensitivity of TEE for the detection of AA atherosclerosis, a negative test result requires verification by additional testing using epiaortic scanning. In case of a positive test result, AA atherosclerosis can be considered as present, and less manipulative strategies might be indicated.
Visualization of the course of the sciatic nerve in adult volunteers by ultrasonography
Authors: BRUHN J. , VAN GEFFEN G.‐J. , GIELEN M. J. , SCHEFFER G. J.
Published: August 2010

Background: The sciatic nerve block by the posterior approaches represents one of the more difficult ultrasound‐guided nerve blocks. Our clinical experiences with these blocks indicated a point slightly distal to the subgluteal fold as an advantageous position to allow good ultrasonic visibility. In this study, we systematically scanned the sciatic nerve from the subgluteal fold to the popliteal crease, to determine an optimal point for ultrasonographic visualization.

Methods: After institutional approval and written informed consent, we recruited 15 volunteers to visualize the sciatic nerve from the subgluteal fold to the popliteal crease using a linear ultrasound probe in the range of 7–13 MHz. The ultrasonographic visibility of the sciatic nerve, nerve diameter (width and thickness), and skin‐to‐nerve distance at 20 equidistant points between the subgluteal fold and the popliteal crease were recorded.

Results: The sciatic nerve could be successfully visualized in cross‐section as a hyperechoic structure on ultrasound in all volunteers. In the course from subgluteal to the popliteal area, the shape of the sciatic nerve changed from flat to round, while the skin–nerve distance varied with the smallest skin–nerve distances at the popliteal crease and at 5.4 cm (on average) distal to the subgluteal fold. The best ultrasonographic visibility scores were found between 7.2 and 10.8 cm (on average) distal to the gluteal fold.

Conclusion: Between 5.4 and 10.8 cm from the subgluteal fold seems to be the best area to scan the sciatic nerve in terms of superficial nerve position and good ultrasonic visibility.
Skin conductance as a means to predict hypotension following spinal anaesthesia
Authors: LEDOWSKI T. , PREUSS J. , KAPILA R. , FORD A.
Published: August 2010

Background and objective: Hypotension following spinal anaesthesia (SA) is common, especially in the elderly. Elevated sympathetic tone has been shown to correlate with severe hypotension after SA. The aim of this prospective trial was to investigate skin conductance (SC), as a measure of sympathetic tone, to predict hypotension after SA.

Methods: After ethical approval and written informed consent, 30 patients undergoing SA were included. Baseline measurements of SC [number of fluctuations per second (reflecting the firing rate of skin sympathetic nerves), area under the curve (AUC) A and B (reflecting the magnitude of the sympathetic impulse)], blood pressure and heart rate were recorded. After administration of SA, all parameters were assessed every 2.5 min for a total of 15 min. Baseline readings of SC were compared with the lowest blood pressure within the study period.

Results: Data from 30 subjects [73 (8) years] were analysed. After SA, the mean arterial blood pressure declined an average of 21.3 (11.3) mmHg. A cut‐off value of 0.35 μSs for baseline AUC B allowed prediction of more than mild hypotension (>15% from baseline) after SA with a sensitivity of 72.5% and a specificity of 77.5%.

Conclusions: AUC B, as a parameter of SC, may predict severe arterial hypotension after SA in the elderly.
Three‐dimensional ultrasound‐assisted popliteal catheter placement revealing aberrant anatomy: implications for block failure
Authors: CLENDENEN S. R. , YORK J. E. , WANG R. D. , GREENGRASS R. A.
Published: August 2010

Background: The current means of introducing continuous sciatic catheters include nerve stimulation, with or without catheter stimulation techniques. More recently, ultrasound has been utilized to facilitate catheter placement.

Methods: This case represents a stimulating catheter‐guided continuous block facilitated by three‐dimensional ultrasound, which revealed aberrant anatomy with proximal and wide bifurcation of the sciatic nerve with implications for block failure.

Results: Before ultrasound imaging secondary failures were attributed to catheter misplacement or dislodgement.

Conclusion: Because of this case observation, our current practice is to use ultrasound confirmation of the bifurcation of the nerve of all popliteal catheter placements, particularly catheters placed in patients having ambulatory procedures to prevent secondary failure of catheters at home.
Fentanyl‐induced cough does not depend on injection speed: a randomized study
Authors: Schäpermeier U. , Hopf H.‐B.
Published: August 2010

Background: The aim of the study was to investigate whether the incidence of cough after intravenous fentanyl depends on the speed of injection.

Methods: With ethics committee approval, 476 ASA class I–III nonsmoking patients free of bronchial hyperreactivity and respiratory tract infection undergoing general anaesthesia for elective surgery were randomized to either 1.5 μg/kg fentanyl injected over 2, 5 or 10 s or placebo (saline) via a periphereal intravenous cannula. The primary endpoint was the incidence of cough within 5 min after completion of injection.

Results: The study was terminated for futility after enrollment of 476 patients because an interim analysis yielded an incidence of cough of 3%, 3% and 6% in the three fentanyl groups, respectively, and of 2% in the placebo group, with no difference between groups (P=0.374, χ2 test for cough between fentanyl and placebo groups).

Conclusions: Under the conditions of our study, the incidence of cough after 1.5 μg/kg fentanyl injected intravenously over 2, 5 or 10 s was between 3% and 6%, unrelated to the speed of injection and not different from placebo.
Sepsis‐related acute kidney injury: a protective effect of drotrecogin alfa (activated) treatment?
Authors: VAN DOORN K. J. , SPAPEN H. , GEERS C. , DILTOER M. , SHABANA W.
Published: August 2010

Background: Drotrecogin alfa activated (DrotAA) is licensed for treatment of patients with severe sepsis and organ failure. Among the latter, acute kidney injury (AKI), defined as the persistence of oligo‐anuria following adequate resuscitation, is one of the most apprehended. We conducted a prospective, observational, and controlled study to test the hypothesis that DrotAA beneficially affected the evolution and outcome of AKI, complicating acute sepsis‐induced cardiopulmonary failure.

Methods: Forty‐six patients were studied. Thirty subjects received standard treatment for sepsis without DrotAA. In the remaining 16 patients, DrotAA was added as a continuous infusion of 24 μg/kg/h for 96 h.

Results: Mean age, causes of sepsis, and severity/organ failure scores were comparable between patients treated with or without DrotAA. Mortality at 28 days was high and comparable between both treatment groups (56% vs. 69%, DrotAA vs. no DrotAA; P=0.5). When oligo‐anuria was present at the start of the study, it persisted during treatment in all patients, with no significant difference between groups. Both treatment groups presented with baseline mean daily fractional excretion of sodium values >2% that remained high during the observation period, regardless of whether DrotAA was given or not. Kidney histology showed a preserved renal architecture with tubular necrosis in all specimens. Similar glomerular, tubulo‐interstitial, and vascular alterations were present in both treatment groups.

Conclusion: In this small cohort of patients with severe sepsis who received adjuvant DrotAA treatment, no effect on urine output, tubular function, or mortality could be demonstrated.
Itraconazole, a potent inhibitor of P‐glycoprotein, moderately increases plasma concentrations of oral morphine
Authors: HEISKANEN T. , BACKMAN J. T. , NEUVONEN M. , KONTINEN V. K. , NEUVONEN P. J. , KALSO E.
Published: August 2010

Background:Individual variation in opioid response is considerable, partly due to pharmacokinetic factors. Transporter proteins are becoming increasingly interesting also in the pharmacokinetics of opioids. The efflux transporter P‐glycoprotein can affect gastrointestinal absorption and tissue distribution, particularly brain access of many opioids. The aim of this study was to evaluate whether itraconazole, which is a potent inhibitor of P‐glycoprotein and CYP3A4, would change the pharmacokinetics or the pharmacodynamics of oral morphine.

Methods:Twelve healthy male volunteers ingested, in a randomized crossover study, once daily 200 mg itraconazole or placebo for 4 days. On day 4, 1 h after the last pre‐treatment dose, the subjects ingested 0.3 mg/kg morphine. Blood samples for the determination of plasma morphine, morphine‐3‐glucuronide (M3G), morphine‐6‐glucuronide (M6G) and itraconazole concentrations were drawn up to 48 h after morphine ingestion. Pharmacodynamic effects were evaluated using a questionnaire, visual analogue scales, a reaction time test, the Digit Symbol Substitution Test and the Critical Flicker Fusion Test.

Results:Itraconazole increased the mean area under the plasma concentration–time curve [AUC (0–9)] of morphine by 29% (P=0.002), its AUC (0–48) by 22% (P=0.013) and its peak plasma concentration by 28% (P=0.035). Itraconazole did not significantly affect the pharmacokinetic variables of M3G or M6G or the pharmacodynamic effects of morphine.

Conclusions:Itraconazole moderately increases plasma concentrations of oral morphine, probably by enhancing its absorption by inhibiting intestinal wall P‐glycoprotein. A possible improvement of morphine penetration to the brain could not be observed.
Effect of remifentanil on oculocardiac reflex in paediatric strabismus surgery
Authors: CHUNG C. J. , LEE J. M. , CHOI S. R. , LEE S. C. , LEE J. H.
Published: August 2010

Background: Rapidly acting narcotics enhance the degree of bradycardia due to the oculocardiac reflex (OCR) elicited by extraocular muscle (EOM) tension during strabismus surgery. We evaluated and compared the effects of remifentanil and sevoflurane on OCR during paediatric strabismus surgery.

Methods: One hundred and twenty children, 1–9 years old, undergoing elective strabismus surgery, were randomly assigned to receive sevoflurane or remifentanil. No anticholinergic prophylaxis was administered. Anaesthesia was induced using ketamine 1.0 mg/kg or midazolam 0.15 mg/kg with 66% N2O in O2. Laryngeal mask airways were placed with rocuronium 0.5 mg/kg. Anaesthesia was maintained with sevoflurane 2.0–3.0 vol% with 66% N2O in O2 or remifentanil 0.75 μg/kg over 1 min and followed by the continuous infusion of remifentanil 0.5 μg/kg/min with 66% N2O in O2. Heart rate (HR) and blood pressure (BP) were measured and compared. OCR was defined as a reduction in HR of >20% induced by traction of an EOM.

Results: During anaesthesia, HR and BP were maintained at a lower level in the remifentanil group than in the sevoflurane group (each, P<0.05). The mean percent change in HR (−23.3±17.0% vs. −11.2±13.0%; P<0.05) and the incidence of OCR (58.3% vs. 28.3%; P<0.05) following traction of an EOM were higher in the remifentanil group than in the sevoflurane group.

Conclusions: Remifentanil enhanced the degree of bradycardia due to OCR as compared with sevoflurane during paediatric strabismus surgery.
Lactobacillus plantarum 299v reduces colonisation of Clostridium difficile in critically ill patients treated with antibiotics
Authors: KLARIN B. , WULLT M. , PALMQUIST I. , MOLIN G. , LARSSON A. , JEPPSSON B.
Published: August 2010

Background: The incidence of Clostridium difficile‐associated disease (CDAD) in hospitalised patients is increasing. Critically ill patients are often treated with antibiotics and are at a high risk of developing CDAD. Lactobacillus plantarum 299v (Lp299v) has been found to reduce recurrence of CDAD. We investigated intensive care unit (ICU) patients with respect to the impact of Lp299v on C. difficile colonisation and on gut permeability and parameters of inflammation and infection in that context.

Methods: Twenty‐two ICU patients were given a fermented oatmeal gruel containing Lp299v, and 22 received an equivalent product without the bacteria. Faecal samples for analyses of C. difficile and Lp299v were taken at inclusion and then twice a week during the ICU stay. Other cultures were performed on clinical indication. Infection and inflammation parameters were analysed daily. Gut permeability was assessed using a sugar probe technique.

Results: Colonisation with C. difficile was detected in 19% (4/21) of controls but in none of the Lp299v‐treated patients (P<0.05).

Conclusions: Enteral administration of the probiotic bacterium Lp299v to critically ill patients treated with antibiotics reduced colonisation with C. difficile.
Selective sensory spinal anaesthesia with hypobaric lidocaine for anorectal surgery
Authors: IMBELLONI L. E. , GOUVEIA M. A. , VIEIRA E. M. , CORDEIRO J. A.
Published: August 2010

Background: Lidocaine has been used for spinal anaesthesia since 1948, seemingly without causing concern until recently. This study aimed at evaluating the feasibility of performing anorectal surgery in outpatient settings with low hypobaric lidocaine doses.

Methods: Three groups of 50 patients, physical status ASA I–II, undergoing anorectal surgical procedures in a prone jack‐knife position, received 3 ml (18 mg), 4 ml (24 mg) or 5 ml (30 mg) of hypobaric 0.6% lidocaine. Sensory and motor blockade, time until first urination, ambulation, complications and the need for analgesics were evaluated. Patients were followed until the third post‐operative day.

Results: Adequate sensory block was obtained in all patients. Blockade was significantly lower in Group 1. The level at 15 min was L1 with 3 ml, T11 with 4 ml and T10 with 5 ml. Only 24 patients presented a moderate motor block. There was no hypotension, nausea or vomiting, urine retention, transitory neurological symptom or post‐dural puncture headache in any patients. There was one case of bradycardia with 4 ml and two cases with 5 ml.

Conclusions: Hypobaric lidocaine predominantly provided a sensory block after injection in the prone jack‐knife position. The smallest dose (3 ml=18 mg) provides sufficient analgesia with a lesser dispersion and a shorter duration. The major advantages were haemodynamic stability and a high degree of patient satisfaction.
Sevoflurane improves myocardial ischaemic tolerance in a closed‐chest porcine model
Authors: LARSEN J. R. , AAGAARD S. , LIE R. H. , SLOTH E. , HASENKAM J. M.
Published: August 2010

Aims: Volatile anaesthetics prevent experimental myocardial ischaemia–reperfusion injury (I/R) in several species, but this finding is partially inconsistent with clinical evidence. Some experimental models may not accurately represent the complex signal transduction pathways triggered by volatile anaesthetics. We therefore investigated sevoflurane I/R prevention in vivo in a porcine model with greater likeness to human physiology than models previously used and compared it with neutral anaesthetic.

Methods and results: Myocardial infarct size [IS/AAR] was compared in three groups of pigs (N=35) randomised to Control anaesthesia (pentobarbital infusion, n=12), sevoflurane inhalation alone (end‐tidal concentration 3.2%) (Sevo, n=9), or both Combined (n=14), throughout ischaemia and reperfusion. Anterior/septal myocardial infarcts resulted from distal LAD coronary artery occlusion by balloon catheter for 45 min followed by 120 min of reperfusion. [IS/AAR] was measured in tetrazolium‐stained heart slices after standardised image processing with computer‐assisted planimetry. Measurements included full invasive monitoring. Control animals developed infarction in 55.0±3.9% (SEM) of the area at risk, Sevo in 17.5±4.4% (P=0.0002), and Combined with pentobarbital in 24.3±3.8% (P=0.0001) of the AAR, sevoflurane reducing infarct size significantly (68% and 60%, respectively).

Conclusions: Sevoflurane markedly decreased myocardial infarct size after prolonged coronary occlusion in a porcine model. In addition to novel sevoflurane cardioprotection in the closed‐chest model, which is more comparable to normal human hearts than models previously used, sevoflurane cardioprotection is substantiated in the juvenile intact organism. The perspectives underline recommending volatile anaesthetics in risk patients and in cardiac surgery.
Establishment of a porcine right ventricular infarction model for cardioprotective actions of xenon and isoflurane
Authors: HEIN M. , ROEHL A. B. , BAUMERT J. H. , BANTES B. , BLEILEVENS C. , BERNSTEIN N. , STEENDIJK P. , ROSSAINT R.
Published: August 2010

Background: Right ventricular (RV) function is an important determinant of post‐operative outcome. Consequences of RV infarction might be limited by pre‐conditioning with volatile anesthetic drugs. Therefore, we used a porcine model of RV ischemia and reperfusion (IR) injury to study the influence of isoflurane and xenon on the extent and degree of myocardial injury.

Methods: IR injury was induced by a 90‐min ligation of the distal right coronary artery and 120‐min reperfusion in thiopental anesthetized pigs. A control group (n=12) was compared with two groups, which received either 0.55 minimum alveolar concentration (MAC) isoflurane (n=10) or xenon (n=12) starting 60 min before ischemia. Myocardial injury was described by three criteria: the infarct size related to area at risk (IS/AAR), the infiltration of neutrophils as determined by myeloperoxidase (MPO) activity, and the plasma levels of tumor necrosis factor α (TNFα), interlukin 6 (IL‐6), myoglobin and troponin‐T (TnT).

Results: IS/AAR was reduced from 58.3±6.2% in the control group to 41.8±7.8% after isoflurane and 42.7±8.5% after xenon pre‐treatment, which equals an absolute reduction of 16.5% [95% confidence interval (CI): 10.9–22.1] and 15.5% (95% CI: 10.1–20.9). The maximum increase of TnT could be observed within the xenon group. Both treatment groups were characterized by lower MPO activity, in the infarct and periinfarct region and lower plasma concentrations of TNFα and IL‐6.

Conclusions: It could be demonstrated for the first time in a model of RV infarction that the continuous application of isoflurane or xenon before, during and after ischemia reduced the extent (size) and severity (inflammation) of myocardial injury.